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Full text of "The AIDS epidemic in San Francisco: the medical response 1981-1984"

Regional Oral History Office 
The Bancroft Library 



University of California 
Berkeley, California 



The San Francisco AIDS Oral History Series 



THE AIDS EPIDEMIC IN SAN FRANCISCO: THE MEDICAL RESPONSE, 1981-1984 

Volume I 



Selma K. Dritz, M.D, M.P.H. 



Mervyn F. Silverman, M.D., M.P.H. 



CHARTING THE EPIDEMIOLOGICAL COURSE 
OF AIDS, 1981-1984 

PUBLIC HEALTH DIRECTOR: THE 
BATHHOUSE CRISIS, 1983-1984 



Introduction by James Chin, M.D., M.P.H. 



Interviews Conducted by 

Sally Smith Hughes 

in 1992 and 1993 



Copyright 1995 by The Regents of the University of California 



Since 1954 the Regional Oral History Office has been interviewing leading 
participants in or well-placed witnesses to major events in the development of 
Northern California, the West, and the Nation. Oral history is a modern research 
technique involving an interviewee and an informed interviewer in spontaneous 
conversation. The taped record is transcribed, lightly edited for continuity and 
clarity, and reviewed by the interviewee. The resulting manuscript is typed in 
final form, indexed, bound with photographs and illustrative materials, and 
placed in The Bancroft Library at the University of California, Berkeley, and 
other research collections for scholarly use. Because it is primary material, 
oral history is not intended to present the final, verified, or complete 
narrative of events. It is a spoken account, offered by the interviewee in 
response to questioning, and as such it is reflective, partisan, deeply involved, 
and irreplaceable. 



This manuscript is made available for research purposes. All 
literary rights in the manuscript, including the right to publish, 
are reserved to The Bancroft Library of the University of 
California, Berkeley. No part of the manuscript may be quoted for 
publication without the written permission of the Director of The 
Bancroft Library of the University of California, Berkeley. 

Requests for permission to quote for publication should be 
addressed to the Regional Oral History Office, 486 Library, 
University of California, Berkeley 94720, and should include 
identification of the specific passages to be quoted, anticipated 
use of the passages, and identification of the user. 

It is recommended that this oral history be cited as follows: 



To cite the volume: The AIDS Epidemic in San 
Francisco: The Medical Response. L98I-1984. Volume I, 
an oral history conducted 1992-1993, The Bancroft 
Library, University of California, Berkeley, 1995. 

To cite an individual interview: [ex.] Selma K. Dritz, 
M.D., M.P.H., "Charting the Epidemiological Course of 
AIDS, 1981-1984," an oral history conducted in 1992 by 
Sally Smith Hughes in The AIDS Epidemic in San 
Francisco: The Medical Response, 1981-1984. Volume I. 
Regional Oral History Office, The Bancroft Library, 
University of California, Berkeley, 1995. 



Copy no. \ 



Cataloguing information 



THE AIDS EPIDEMIC IN SAN FRANCISCO: THE MEDICAL RESPONSE, 1981-1984, VOLUME 
I, 1995, xv, 276 pp. 

Selma K. Dritz (b. 1917), epidemiologist, San Francisco Department of 
Public Health, 1967-1984; enteric disease in gay community; early cases of 
AIDS: etiology, diagnosis, risk groups; San Francisco General Hospital's 
Kaposi's Sarcoma Clinic; transfusion AIDS; Medical Advisory Committee on 
AIDS formed; June 1982 meeting, New York City, on AIDS opportunistic 
infections; San Francisco bathhouse issue; discussion of funding, AIDS 
drugs, AIDS in women. Mervyn F. Silverman (b. 1938), director, San 
Francisco Department of Public Health, 1977-1986; health department links 
with San Francisco's gay community; AIDS education strategy, programs; 
hospital admission of AIDS patients; the San Francisco model of AIDS care; 
the bathhouse issue; AIDS testing, and AIDS drugs; AIDS and the media and 
the federal government response; funding for AIDS. Appendices include AIDS 
Chronology, 1981-1984, list of key participants, documents from 
interviewees . 

Introduction by James Chin, M.D., M.P'.H., Clinical Professor of 
Epidemiology, School of Public Health, University of California, Berkeley 

Interviews conducted 1992 and 1993 by Sally Smith Hughes, Ph.D for the San 
Francisco AIDS Oral History Series. The Regional Oral History Office, The 
Bancroft Library, University of California, Berkeley. 



ACKNOWLEDGEMENTS 



The Regional Oral History Office wishes to express deep gratitude to 
Evelyne and David Lennette of Virolab, Inc., for their financial support of 
this project, incisive conceptual contributions, and sustaining interest 
and enthusiasm. 



TABLE OF CONTENTS- -The AIDS Epidemic in San Francisco: The Medical 
Response, 1981-1984, Volume I 

PREFACE--by David and Evelyne Lennette i 

SERIES INTRODUCTION- -by James Chin iii 

SERIES HISTORY--by Sally Smith Hughes vi 

INTERVIEW WITH SELMA K. DRITZ 

INTERVIEW HISTORY--by Sally Smith Hughes 
BIOGRAPHICAL INFORMATION 

I EDUCATION AND EARLY CAREER 1 

Education 1 

Early Career 1 

Pre-San Francisco 1 

Epidemiologist, San Francisco Department of Public Health, 

1967-1984 4 

Enteric Disease in the Gay Community 5 

II THE AIDS EPIDEMIC 10 

Early Cases of AIDS 10 

Kaposi's Sarcoma 10 

Pneumocystis carinii Pneumonia 11 

Kaposi's Sarcoma Study Group and Clinic 13 

Simon Guzman: An Early Patient 14 

Investigating the Etiology of AIDS 15 

Possible Causes 15 

The CDC Questionnaire 15 

Suspicions of a Transmissible Agent 17 

Diagnosing AIDS 17 

Recognizing Immune Suppression 20 

More on Etiology 21 

Retrovirology 22 

AIDS Progression 25 

Risk Groups 25 

Press Coverage 26 

Funding Problems 27 

More on the Kaposi's Sarcoma Clinic 29 

Support from Community Groups 31 

The Health Department's Community Ties 32 



Gaetan Dugas and the Cluster Study 34 

Transfusion AIDS at UCSF 36 

The Centers for Disease Control Blood Transfusions Workshop/ 

Advisory Committee Meeting, January 4, 1983 39 

Testing Blood for Viruses 44 
The Medical Advisory Committee on AIDS, San Francisco Department 

of Public Health 46 

Purpose and Membership 46 

Giving Advice 47 

The Bathhouses 49 

Fear of Infection 51 

San Francisco Medical Society 52 

San Francisco Board of Supervisors 52 

Health Department Relationships with Other Agencies 53 

Local, State, and Federal Agencies 53 

The News Media 55 

Private Physicians and Other Health Departments 55 

San Francisco Coroner's Office 56 

Confidentiality 56 

The HIV Antibody Test 57 

Gay Issues 61 

Meeting on Kaposi's Sarcoma and Opportunistic Infections, New 

York City, July 13, 1982 62 

Medical Grand Rounds on AIDS, July 1983 69 

Stuart Anderson and Vitamin C 71 

Lecturing on AIDS 72 

Learning to Recognize Opportunistic Infections 74 

The Health Department's AIDS Program 75 

Development of Program Components 75 

Education Program 78 

The Department's Ties with Various San Francisco Organizations 82 

San Francisco Men's Health Study 84 

The Bathhouses 85 

Meeting with the Bathhouse Owners, 1982 86 

Relying on the Gay Community for Information 87 

Threat of a Temporary Restraining Order 88 

Open Hearing at the Health Department, March 30, 1984 89 

Bathhouse Closure, October 9, 1984 90 

Divided Opinion in the Gay Community 92 

The Continuing Problem of AIDS Etiology 93 

The Effects of Insufficient Funding 94 

Testing Stored Hepatitis B Blood for HIV Antibody 95 

The Impact of Discovering the AIDS Virus 96 

Broadening the Definition of AIDS 99 

Health Care Workers and the Risk of AIDS 100 

Finding Treatment for AIDS 102 

Accelerated Approval of AIDS Drugs 103 

AIDS in Women 104 

Retirement 105 



INTERVIEW WITH MERVYN F. SILVERMAN 

INTERVIEW HISTORY--by Sally Smith Hughes 
BIOGRAPHICAL INFORMATION 

I EDUCATION AND CAREER 107 

Education and Early Career 107 

Interest in Public Health 108 

Director, San Francisco Department of Public Health, 1977-1986 109 

Comparison with the Department of Public Health in Kansas 109 

Relations with Other San Francisco Institutions 110 

Threat to Remove the Health Department's Jurisdiction over 

San Francisco General Hospital 112 

Departmental Links with the Gay Community 113 

II THE AIDS EPIDEMIC 115 

Becoming Aware of the Epidemic 115 

Turf Battles 116 

Conceptualizing AIDS as a Gay Disease 117 

AIDS Education Programs 118 

Educational Approach 118 

Attacks by Randy Shilts and Harry Britt 119 

Diversity within the Gay Community 122 

Complexity of the AIDS Problem ' 123 

The AIDS Activity Office 124 

Selma Dritz 126 

Hospital Admission of AIDS Patients 127 

Initial Opposition to the AIDS Ward 129 

San Francisco's Unique Response to the Epidemic 130 

The Health Director's Powers 133 

The Health Director's Medical Advisory Committee on AIDS 133 

The Community Advisory Committee on AIDS 135 

AIDS Screening Clinics 135 

Government's Role 137 

More on AIDS Education 138 

Strategy 138 

More Criticism 140 

City Money for AIDS Services 140 

The Census Track Study, 1983 142 

The Bathhouse Episode, 1983-1984 143 

Regulation Rather than Closure 143 

City Attorney's Opinion 145 

Deciding on Education Rather than Closure 146 

Paul Lorch's Editorial 149 

Press Conference on Regulations, April 9, 1984 149 

Reactions from the Gay Community 150 

Canceling the March 30, 1984 Press Conference 152 

Deciding to Close the Bathhouses 156 

The Mayor's Reaction 156 

Leon McKusick's Studies 158 

The Baths Reopen 159 



Civil Liberties versus Public Health 160 

Assessing the Decision Regarding Closure 163 

Resigning as Health Director 165 

Silverman's Recent Positions 169 

Testing Advocate 171 

Blood Screening 172 

Setting Up Anonymous Testing Sites 172 

The Epidemic's Impact on Medicine 173 

The Doctor-Patient Relationship 173 

Accelerated Drug Approval 175 

San Francisco Model of AIDS Care 177 

Definition 177 

Transfer of the Concept 178 

Robert Wood Johnson AIDS Health Services Program 179 

The Media 181 

The Federal Government's Response to the Epidemic 182 

TAPE GUIDE 185 

APPENDICES 186 

A. AIDS Chronology, 1981-1984 187 

B. Key Participants in San Francisco AIDS History, 1981-1984 199 

C. Dritz materials--San Francisco City Clinic Forms and Guidelines 202 

D. Curriculum vitae, Selma K. Dritz, M.D. , M.P.H 230 

E. Silverman materials documents relating to the closing of the 
bathhouses 234 

F. Curriculum vitae, Mervyn F. Silverman, M.D., M.P.H. 268 
INDEX 272 



PREFACE--by David A. Lennette, Ph.D., and Evelyne T. Lennette, Ph.D. 



As two young medical virologists working in Pennsylvania, we 
experienced first hand some of the excitement of medical detective work. 
We had our first glimpse of how personalities can shape the course and 
outcome of events during the swine influenza and Legionnaires' disease 
outbreaks. 

On our return to California, we were soon embroiled in another much 
more frightening epidemic. In 1981, our laboratory began receiving 
samples for virologic testing from many of the early San Francisco AIDS 
patientswhose names are now recorded in Randy Shilts' book And the Band 
Played On. Our previous experience with the legionellosis outbreak had 
primed us for this new mystery disease. While the medical and scientific 
communities were hotly debating and coping with various issues during the 
following three years, we were already subconsciously framing the 
developments in an historical point of view. In San Francisco, dedicated 
junior physicians and researchers banded together to pool resources and 
knowledge out of necessity, and in doing so, organized part of the local 
medical community in a very unusual way. Once again, we were struck by 
how the personalities of each of these individuals shaped the course of 
events. Even before HIV was discovered, we knew we were witnessing a new 
page in the history of science and medicine. 

The swine flu and legionellosis outbreaks were both very local and 
short lived. We now speak of them in the past tense. The AIDS epidemic, 
sadly, is still spreading unimpeded in much of the world. We know that 
it will be with us for a long time and that it is very unlikely that 
either of us will live long enough to read the closing chapter on AIDS. 

Future generations will some day want to know how it all got 
started. The existing scientific reports and publications provide 
depersonalized records of some of the events, while newspaper articles 
and books give glimpses as summarized by observers. What are missing are 
the participants' own accounts and perspectives. 

It is now more than a dozen years after the recognition of the AIDS 
epidemic in the United States. So much has happened and changed-- 
already, some of the participants in early events have retired, records 
are being discarded and destroyed, and memories of those days are 
beginning to fade. We felt their oral histories had to be recorded 
without delay. 

We had previously sponsored oral histories on virology with Dr. 
Edwin H. Lennette, David's father, and Dr. Harald N. Johnson, and were 



ii 



familiar with the methods and work of the Regional Oral History Office. 
We met to talk over the recording of the AIDS epidemic with Willa Baum, 
head of the office, and Dr. Sally Smith Hughes, medical history 
interviewer. After some discussion, we agreed that the events from 1981- 
1984 needed to be documented and we would fund it. This was a time when 
many crucial decisions on the clinical, public health, social, and 
political issues pertaining to AIDS were made with little scientific 
information and no precedents to rely on. The consequences of many of 
these decisions are still being felt today. With the discovery of HIV, 
however, the framework for decision making shifted to different ground, 
and a pioneering phase was over. Once we decided on the scope of the 
project, it was a simple task to identify prospective interviewees, for 
we worked with many of these individuals during those years. 

Dr. Sally Hughes has shared our enthusiasm from the beginning. We 
are pleased that her efforts are now coming to fruition. 



David A. Lennette, Ph.D. 
Evelyne T. Lennette, Ph.D. 



November 1994 
Virolab, Inc. 
Berkeley, California 



iii 



SERIES INTRODUCTION- -by James Chin, M.D., M.P.H. 



As the California state epidemiologist responsible for communicable 
disease control from the early 1970s to the late 1980s, I had the 
privilege and opportunity to work with all of the participants who were 
interviewed for the San Francisco AIDS Oral History Project. I consider 
it an honor to have been asked to provide a brief introduction to the 
role that these individuals played in the history of AIDS in San 
Francisco during the early years. Before I begin, the following quote 
from Dr. James Curran, in a December 1984 issue of the San Francisco 
Chronicle sums up what has happened to all of the participants in this 
oral history project: 

I'd like to sound more upbeat about this, but there are some 
unavoidable facts we need to face. AIDS is not going away. 
Gay men don't want to hear that. Politicians don't want to 
hear that. I don't like to hear that. But for many of us, 
AIDS could well end up being a lifelong commitment. 

The first recognized cases of AIDS were reported in the Morbidity 
and Mortality Weekly Report (MMWR) on June 5, 1981. I recall this report 
vividly. A few months earlier, the Centers for Disease Control (CDC) had 
begun sending an advance copy of the MMWR text to state health 
departments. The advance text of the June 5 MMWR had a lead article on 
the sudden and unexplained finding of five apparently unrelated cases of 
Pneumocystis carinii pneumonia in five young gay men from Los Angeles. 
The MMWR text was received in my office just before our weekly Tuesday 
afternoon staff meeting was to start. I handed the text to Tom Ault, who 
was responsible for the state's venereal disease field unit and asked him 
to have some of our federal- or state-assigned staff in Los Angeles 
assist in the investigation of these cases. I remember saying to him 
that it may not turn out to be much of anything, but it may be the start 
of something. I never imagined that that something would eventually 
develop into a worldwide epidemic of disease and death. 

In the ensuing weeks and months, it became apparent that the 
mysterious illness reported from Los Angeles was also present among gay 
men in San Francisco. From 1981 to 1984, the numbers of AIDS cases 
reported from San Francisco rose almost exponentiallyfrom a handful in 
mid- 1981 to well over 800 towards the end of 1984. The impact that AIDS 
has had in San Francisco is unequaled on a per capita basis anywhere in 
the developed world. If the AIDS prevalence rate of about one AIDS case 
per 1,000 population that was present in San Francisco at the end of 1984 
was applied nationally, then there would have been about a quarter of a 
million AIDS cases nationwide instead of the 7,000 that were actually 



iv 



reported. During the first few years of what was initially referred to 
as GRID (gay-related immune deficiency), there was general denial of the 
severity of this newly recognized mystery disease even in San Francisco. 
The enormity of the AIDS problem was first fully accepted by the gay 
community in San Francisco, and physicians and researchers in the city 
rapidly became the leading experts in the country on the medical 
management, prevention, and control of AIDS. In contrast to Los Angeles 
and New York, which also have had large concentrations of AIDS cases, the 
gay community in San Francisco has been more unified and organized in 
developing political and community support for the treatment and care of 
AIDS patients. 

The epidemiology of AIDS, namely, that it is caused primarily by a 
sexually transmitted agent, was fairly well established by 1983, well 
before HIV was eventually isolated and etiologically linked to AIDS in 
1984. Public health investigations in San Francisco, spearheaded by 
Selma Dritz in 1981 and 1982, provided much of the key epidemiologic data 
needed to understand the transmission and natural history of HIV 
infection. The more formal epidemiological studies of AIDS among gay men 
in San Francisco were carried out by Andrew Moss at San Francisco General 
Hospital (SFGH) and Warren Winkelstein at the University of California at 
Berkeley. All of these studies were helpful to Mervyn Silverraan (who 
during this period was director of the San Francisco Department of Public 
Health) to support his decision in October 1984 to close the San 
Francisco bathhouses. Selma Dritz retired from her position with the 
health department in 1984, and Mervyn Silverman has moved on to become 
the premier HIV/AIDS frequent flier in his current position as president 
of the American Foundation for AIDS Research, which is now supporting 
studies internationally. 

Jay Levy was an established virologist when AIDS was first detected 
and reported in 1981. His laboratory isolated and characterized a virus 
which he initially called ARV--AIDS Related Virus. He continues to play 
a prominent role in the quest to better understand the pathogenesis of 
HIV. Herbert Perkins was the scientific director of the Irwin Memorial 
Blood Bank in San Francisco during the critical period around 1982-1985 
when data began accumulating to indicate that the cause of AIDS might be 
an infectious agent which could be transmitted via blood. Under his 
direction, the Irwin Memorial Blood Bank in May 1984 was the first blood 
bank in the country to begin routine surrogate testing of blood units for 
the AIDS agent using a hepatitis B core antibody test. He retired as 
director of Irwin Memorial in April 1993, but remains very much involved 
in defending the blood bank from legal suits arising from transmission of 
HIV via blood transfusions during the early years. Don Francis did not 
work in California during the early 1980s, but directed epidemiologic and 
laboratory studies on AIDS as the first head of the AIDS laboratory at 
CDC in Atlanta during this time period. Following his request to become 
more directly involved with field work and HIV/AIDS program and policy 



development, he was assigned to work in my office in Berkeley in 1985. 
Don took an early retirement from CDC in 1992 and continues to actively 
work in the San Francisco Bay Area as well as nationally and 
internationally on the development of an AIDS vaccine. 

The clinical staffs of San Francisco General Hospital and the 
University of California at San Francisco established the two earliest 
AIDS clinics in the country, and in 1983, Ward 5B at SFGH was set up 
exclusively for AIDS patients. In the early 1980s, Don Abrams and Paul 
Volberding were two young physicians who found themselves suddenly thrust 
into full-time care of AIDS patients, a responsibility which both are 
still fully involved with. As a result of their positions, experience, 
and dedication, both are acknowledged national and international experts 
on the drug treatment of HIV and AIDS patients. Merle Sande, John 
Ziegler, Arthur Ammann, and Marcus Conant were already well established 
and respected clinicians, researchers, and teachers when AIDS was first 
detected in San Francisco. Their subsequent work with HIV/AIDS patients 
and research has earned them international recognition. The Greenspans, 
Deborah and John, have established themselves as the foremost experts on 
the oral manifestations of HIV/AIDS, and Constance Wofsy is one of the 
leading experts on women with HIV/AIDS. There is rarely a national or 
international meeting or conference on AIDS where most, if not all, of 
these San Francisco clinical AIDS experts are not present and speaking on 
the program. The number of HIV/AIDS clinicians and research scientists 
from San Francisco invited to participate in these medical and scientific 
meetings usually far exceeds those from any other city in the world. All 
of these individuals have made tremendous contributions to the medical 
and dental management of HIV/AIDS patients in San Francisco and 
throughout the world. 

As of late 1994, more than a decade since the advent of AIDS in San 
Francisco, Jim Curran's remark in 1984 that "...for many of us, AIDS 
could well end up being a lifelong commitment" has been remarkably 
accurate for virtually all the participants in this San Francisco AIDS 
Oral History Project. 

James Chin, M.D., M.P.H. 
Clinical Professor of Epidemiology 
School of Public Health, University of 
California at Berkeley 

September 1994 
Berkeley, California 



vi 



SERIES HISTORY--by Sally Smith Hughes 



Historical Framework 

In 1991, Evelyne and David Lennette, virologists and supporters of 
previous Regional Oral History Office (ROHO) projects in virology and 
horticulture, conceived the idea for an oral history series on AIDS. They 
then met with Willa Baum (ROHO director) , and me to discuss their idea of 
focusing the series on the medical and scientific response in the early 
years (1981-1984) of the AIDS epidemic in San Francisco, believing that the 
city at this time played a particularly formative role in terms of AIDS 
medicine, organization, and policy. Indeed San Francisco was, with New York 
and Los Angeles, one of the three focal points of the epidemic in the United 
States, now sadly expanded worldwide. 

The time frame of the oral history project is historically significant. 
Nineteen eighty-one was the year the epidemicnot until the summer of 1982 
to be officially christened "AIDS"--was first recognized and reported. The 
cause, human immunodeficiency virus (HIV), was reported in 1984, and by 
early 1985, diagnostic tests for HIV were being marketed. These 
achievements signaled a turning point in the response to the epidemic. Its 
science shifted from a largely epidemiological approach to one with greater 
emphasis on the laboratory. As soon as the virus was isolated, scientific 
teams in the United States and Europe raced to characterize it in molecular 
terms. Information about the molecular biology of HIV was in turn expected 
to transform AIDS medicine by providing a basis for treatment and prevention 
of the disease through new drugs and vaccines. 

San Francisco continued to make important contributions to combating 
the epidemic, but by early 1985 it had lost its pioneering role. The AIDS 
test showed that the epidemic reached far beyond the three original 
geographic centers and involved large numbers of symptomless HIV-positive 
individuals, who were not identifiable prior to the test's advent. AIDS 
funding increased; the number and location of AIDS researchers expanded; 
research interest in the newly identified virus took center stage. San 
Francisco's salient position in the AIDS effort faced competition from new 
players, new research interests, and new institutions. The first phase of 
the epidemic was history. 



Project Structure 

Within the limits of funding and the years of the project (1981-1984), 
the Lennettes suggested eight potential interviewees whom they knew to play 
important medical and scientific roles in the early years of the San 
Francisco epidemic. (Both Lennettes have close connections with the local 
AIDS research community, and Evelyne Lennette was a scientific collaborator 



vii 



of three interviewees in this series, Jay Levy and Deborah and John 
Greenspan.) I then consulted Paul Volberding, an oncologist at San 
Francisco General Hospital with an international reputation as an AIDS 
clinician. He and others in the oral history series made several 
suggestions regarding additional interviewees, expanding my initial list to 
fourteen individuals. 1 My reading of primary and secondary sources and 
consultation with other authorities confirmed the historical merit of these 
choices. 

The series consists of two- to ten-hour interviews with fourteen 
individuals in epidemiology, virology, public health, dentistry, and several 
medical specialties. By restricting phase one to San Francisco's early 
medical and scientific response to the epidemic, we aim to provide in depth 
documentation of a major aspect, namely the medicine and science it 
generated in a given location, at a given time, under near-crisis 
conditions. Like any human endeavor, medicine and science are embedded in 
the currents of the time. As these oral histories so graphically 
illustrate, it is impossible to talk about science and medicine without 
relating them to the social, political, and institutional context in which 
they occur. One of the strengths of oral history methodology is precisely 
this. 

This concentration on physicians and scientists is of course elitist 
and exclusive. There is a limitpractical and f inancial--to what the first 
phase of a project can hope to accomplish. It was clear that the series 
needed to be extended. Phase two of the oral history project, a series with 
AIDS nurses, is underway and serves to broaden the focus. The long-range 
plan is to interview representatives of all sectors of the San Francisco 
community which contributed to the medical and scientific response to AIDS, 
thereby providing balanced coverage of the city's medical response. 



Primary and Secondary Sources 

This oral history project both supports and is supported by the written 
documentary record. Primary and secondary source materials provide 
necessary information for conducting the interviews and also serve as 
essential resources for researchers using the oral histories. They also 
orient scholars unfamiliar with the San Francisco epidemic to key 
participants and local issues. Such guidance is particularly useful to a 
researcher faced with voluminous, scattered, and unorganized primary 
sources, characteristics which apply to much of the AIDS material. This 



1 A fifteenth was added in 1994, when the UCSF AIDS Clinical 
Research Center provided partial funding for interviews with Warren 
Winkelstein, M.D., M.P.H., the epidemiologist directing the San Francisco 
Men's Health Study. 



Vlll 



two-way "dialogue" between the documents and the oral histories is essential 
for valid historical interpretation. 

Throughout the course of this project, I have conducted extensive 
documentary research in both primary and secondary materials. I gratefully 
acknowledge the generosity of Drs. Arthur Ammann, Marcus Conant, John 
Greenspan, Herbert Perkins, Warren Winkelstein, and John Ziegler in opening 
to me their personal documents on the epidemic. Dr. Frances Taylor, 
director of the Bureau of Infectious Disease Control at the San Francisco 
Department of Public Health, let me examine documents in her office related 
to closure of city bathhouses in 1984. Sally Osaki, executive assistant to 
the director of the health department, gave me access to documents from 
former Mayor Dianne Feinstein's papers on her AIDS activities. I am 
grateful to both of them. 

Dr. Victoria Harden and Dennis Rodrigues of the NIH Historical Office 
assisted by sending correspondence and transcripts of a short telephone 
interview with John Ziegler, which Rodrigues conducted. 1 I thank Dr. James 
Chin for his introduction to this series, which describes his first-hand 
experience of the epidemic as state epidemiologist at the California 
Department of Health Services where he was responsible for communicable 
disease control. I also thank Bill Walker, archivist of UCSF's AIDS History 
Project and the San Francisco Gay and Lesbian Historical Society, for his 
assistance in accessing these rich archival collections. 

The foregoing sources have been crucial in grounding the interviews in 
specifics and in opening new lines of questioning. A source to be noted, 
but untapped by this project, is the California AIDS Public Policy Archives, 
which is being coordinated by Michael Gorman, Ph.D. , at San Francisco 
General Hospital. 

Of the wealth of secondary historical sources on AIDS, the most 
pertinent to this project is Randy Shilts 1 And the Band Played On. 2 
Although criticized for its political slant, it has been invaluable in 
providing the social, political, and ideological context of early AIDS 
efforts in San Francisco, particularly in regard to San Francisco's gay 
community. 



1 Telephone interview by Dennis Rodrigues with John L. Ziegler, 
M.D., January 5, 1990. Tapes and transcripts of the interview are 
available in the NIH Historical Office, Bethesda, MD. 

2 Randy Shilts. And the Band Played On: Politics, People, and the 
AIDS Epidemic. New York: Penguin Books, 1988. 



ix 



Oral History Process 

The oral history methodology used in this project is that of the 
Regional Oral History Office, founded in 1954 and producer of well over one 
thousand archival oral histories. The method consists of background 
research in primary and secondary sources; systematic recorded interviews; 
transcription, editing by the interviewer, and review and approval by the 
interviewee; deposition in manuscript libraries of bound volumes of 
transcripts with table of contents, introduction, interview history, and 
index; cataloging in national on-line library networks (MELVYL, RLIN, and 
OCLC); and publicity through ROHO news releases and announcements in 
scientific, medical, and historical journals and newsletters. 

Oral history as an historical technique has been faulted for its 
reliance on the vagaries of memory, its distance from the events discussed, 
and its subjectivity. All three criticisms are valid; hence the necessity 
for using oral history documents in conjunction with other sources in order 
to reach a reasonable historical interpretation. 1 Yet these acknowledged 
weaknesses of oral history, particularly its subjectivity, are also its 
strength. Often individual perspectives provide information unobtainable 
through more traditional sources. For example, oral history in skillful 
hands provides the context in which events occurthe social, political, 
economic, and institutional forces which shape the evolution of events. It 
also places a personal face on history which not only enlivens past events 
but also helps to explain how individuals affect historical developments. 

The foregoing criticisms could be directed at the AIDS oral history 
series. Yet this series has several mitigating characteristics. First, it 
is on a given topic in a limited time frame with interviewees focused on a 
particular response, namely the medical and scientific. Thus although each 
interviewee presents a distinctive view of the epidemic, multiple 
perspectives on the same events provide an opportunity for cross-checking 
and verification, as well as rich informational content. Furthermore, with 
the exception of Dr. Selma Dritz who retired in 1984, each interviewee 
continues to be actively engaged in AIDS work. Hence, the memory lapses 
resulting from chronological and psychological distancing from events 
discussed are less likely to occur than when the interviewee is no longer 
involved. 2 



1 The three criticisms leveled at oral history also apply in some 
cases to other types of documentary sources. 

2 I discussed some of the advantages and disadvantages of oral 
history conducted with interviewees "in the heat of the battle", that is, 
while still engaged in the event being discussed, in an unpublished paper 
presented at the annual meeting of the Oral History Association, 
November, 1993. 



An advantage of a series of oral histories on the same topic is that 
the information each contains is cumulative and interactive. Through 
individual accounts, a series can present the complexities and 
interconnections of the larger picture in this case, the medical and 
scientific aspects of AIDS in San Francisco. Thus the whole (the series) 
is greater than the sum of its parts (the individual oral histories), and 
should be considered as a totality. To encourage this approach, we decided 
to bind several oral histories together in each volume. 

Another feature of an oral history series is that later interviews tend 
to contain more detailed information because as the series unfolds the 
interviewer gains knowledge and insight from her informants and from 
continued research in primary and secondary sources. This was indeed the 
case in the AIDS series in which the later interviews benefited from my 
research in private document collections made available to me as the project 
progressed and by the knowledge I gained from the interviews and others 
connected with the AIDS scene. 

A feature of this particular series is its immediacy, a characteristic 
less evident in oral histories conducted with those distanced from the topic 
of discussion. These are interviews with busy people who interrupted their 
tight schedules to look back, sometimes for the first time, at their 
experiences a decade or so ago. Because many have not had the luxury of 
time to contemplate the full meaning of their pasts, the oral histories 
could be criticized for lacking "historical perspective." But one could 
also argue that documents intended as primary historical sources have more 
scholarly value if the information they contain is not filtered by the 
passage of years and evolving personal opinions. 

The oral histories also have a quality of history-in-progress. With 
one exception, the interviewees are still professionally engaged in and 
preoccupied by an epidemic which unhappily shows no sign of ending. The 
narrators are living the continuation of the story they tell. Neither they 
nor we can say for sure how it will end. 



Other Oral History Prelects Related to AIDS 

Oral history projects on other aspects of the San Francisco epidemic 
are essential for full historical documentation and also mutually enrich one 
another. Unfortunately, not enough is currently being done in this regard. 
Two local projects are Legacy, directed by Jeff Friedman, which focuses on 
the Bay Area dance community tragically decimated by AIDS, and Clarissa 
Montanaro's AIDS Oral History Project, which interviews people with AIDS. 
An installation, "Project Face to Face", directed by Jason Dilley and using 
excerpts from interviews with people with AIDS, was exhibited around the San 
Francisco Bay Area and in 1991 was part of the inaugural exhibit at the 
Smithsonian's Experimental Gallery. 



xi 



AIDS oral history projects outside San Francisco include documentation 
by Victoria Harden, Ph.D., and Dennis Rodrigues of the NIH Historical Office 
of the contribution made by NIH scientists, physicians, and policymakers to 
the AIDS effort. The New Jersey AIDS Oral History Project, sponsored by the 
University of Medicine and Dentistry of New Jersey, interviews faculty and 
staff involved in the epidemic and representatives of organizations 
providing AIDS support services. Rosa Haritos, Ph.D., at Stanford relied 
substantially on oral history in her dissertation on the controversy between 
the Pasteur Institute and NIH over the discovery of the AIDS virus. 1 In 
England, Virginia Berridge, Ph.D., co-director of the AIDS Social History 
Programme at the London School of Hygiene and Tropical Medicine, employs 
oral history in her research on AIDS policy in the UK. 2 And Maryinez Lyons, 
Ph.D., at the University of London, uses interviews in her work on the 
political economy of AIDS in Uganda. 3 In France, Anne Marie Moulin, M.D., 
Ph.D., Director of Research at INSERM, Paris, has relied on oral history in 
some of her work on the epidemic in France. The anthropologist, Paul 
Farmer, used interviews heavily in his work on AIDS in Haiti. 4 



Emerging Themes 

What themes can be extracted from these oral histories? What do they 
convey about the medical response to AIDS in San Francisco? Was it unique, 
or are there parallels with responses to other epidemics? What do these 
interviews tell us about the complex interweaving of factors social, 
political, economic, and personalwhich shaped reactions to this epidemic, 
in this city, in these years? 

The short answer is that it is too soon to attempt definitive answers. 
This is the first volume in a lengthy series, and most of the oral histories 



1 Rosa Haritos. Forging a Collective Truth: A Sociological 
Analysis of the Discovery of the AIDS Virus. Ph.D. dissertation, 
Colubmia, 1993. 

2 See: Virginia Berridge and Paul Strong, eds. AIDS and 
Contemporary History. Cambridge: Cambridge University Press, 1993. 

3 Maryinez Lyons. AIDS and the Political Economy of Health in 
Uganda, paper presented at a conference, AIDS and the Public Debate: 
Epidemics and their Unforeseen Consequences, sponsored by the AIDS 
History Group of the American Association for the History of Medicine, 
Lister Hill Center, NIH, Bethesda, MD, October 28-29, 1993. 

4 Paul E. Farmer. AIDS and Accusation: Haiti and the Geography of 
Blame. Berkeley: University of California Press, 1992. 



xii 



are not completely processed nor has the information they contain been fully 
assessed. 

Furthermore, there is an inherent danger in reaching definitive 
conclusions on the basis of oral histories with only fifteen individuals. 
Obviously, this is not a statistical sampling. On the other hand, because 
these fifteen have been at the front line of the epidemic arid in a city hit 
hard by the epidemic, their voices "count" more than their numbers might 
suggest. They also "count" because these individuals helped devise 
organizations and policies that have served as models for AIDS programs 
across the country and around the world. Thus, if used in conjunction with 
the traditional documentary sources, these oral histories "count" as rich 
historical sources on several levels. 

Remembering these caveats, I will make some tentative suggestions about 
a few of the many themes which come to the fore as I put the first volume 
together. My thoughts will doubtless be modified and extended as I examine 
the oral history collection as a whole and assess it in the context of the 
existing literature on AIDS history. 

--Professional and personal "preparation" for the epidemic: 

Narrators invariably mentioned how their prior education and 
professional training and experience had prepared them for participation in 
the epidemic. Their training as oncologists or epidemiologists or 
infectious disease specialists "fitted them" in a deterministic sense to 
take notice when the epidemic was first recognized in San Francisco. Their 
interest piqued, they chose to become engaged because their professional 
knowledge, experience, and responsibility placed them in a position to 
contribute. How then to explain why others with similar backgrounds chose 
not to become involved? The interviews indicate that psychological makeup, 
humanitarian concerns, career ambition, absence of prejudice, and simply 
being needed and on the scene also played a role. 

--Organizing for the epidemic: 

The oral histories describe at length, in detail, and on many levels 
how the medical profession in San Francisco organized to respond to the 
epidemic. The focus is on physicians, but the oral histories show that it 
is impossible to talk about the medical response without at the same time 
mentioning its interconnections with the nursing, psychiatric, and social 
service professions, the gay community, and volunteer AIDS support 
organizations. Discussion of the coordinated medical system created in the 
early years of the epidemic, capsulized in the so-called San Francisco model 
of comprehensive AIDS care, permeates the oral histories. The complex 
process by which a community organizes to diagnose, investigate, and treat 
a newly recognized disease is detailed here, as are the spinoffs of these 
activities the foundation of two AIDS clinics, an AIDS ward, and a specimen 



xiii 



bank; funding efforts; education and prevention programs; epidemiological 
and laboratory studies; political action at the city, state, and national 
levels; and so on. 

--The epidemic's impact on the professional and personal lives of physicians 
and scientists: 

A strength of oral history is its personal voice; its facility at 
putting a human face on history. The personal dimension makes history come 
alive and also helps to explain why events took the course they did. Its 
subjectivity is also an object of criticism. Hence the scholar's imperative 
to use oral history only in conjunction with the written documentary record. 

Surprisingly, despite the flood of AIDS literature and the centrality 
of the medical profession in the epidemic, there are few accounts by 
physicians of the epidemic's professional and personal impact. 1 The 
physicians' voices which speak--at times poignantly, but always with 
immediacythrough these oral histories are a small corrective to the 
impersonality of most of the literature on AIDS. 

On a professional level, the narrators describe commitment, concern, 
cooperation, camaraderie, and conflict as attributes of their engagement in 
the epidemic. Clinicians and epidemiologists confronted by what they 
perceived as a medical emergency described the prevailing sense of urgency 
and dedication of the epidemic's early yearsto stop the insidious spread 
of disease, to discover its cause, to devise effective treatments, to 
establish community care arrangements. Narrators talked of concern for an 
articulate, informed, and youthful patient population, with whom some 
identified and for whom most felt great sympathy. They also spoke of the 
camaraderie and cooperation of the physicians, nurses, social workers, and 
community volunteers assembled at UCSF and San Francisco General to run the 
AIDS clinics and ward. But they also mentioned conf lict--personal and 
institutional rivalries, funding problems, and run-ins with the university 
administration, city politicians, and gay activists. 

On a personal level, the interviews recount the epidemic's impact on 
individual livesof fear of a devastating and lethal infection, of stigma 
and homophobia involved in dealing with socially marginal patient 
populations, of exhaustion and burnout, and of growth in human experience 
and insight. 



1 A few personal accounts by physicians do exist. See, for example: 
G. H. Friedlander. Clinical care in the AIDS epidemic. Daedalus 1989, 
118, 2:59-83. H. Aoun. When a house officer gets AIDS. New England 
Journal of Medicine 1989, 321:693-696. 



xiv 



--The epidemic as a social and cultural phenomenon: 

These oral histories describe the complex interactions between disease 
and its social and cultural context. They indicate how the unique 
circumstances of San Francisco in the early 1980s--its large and vocal gay 
community, its generally cooperative medical and political establishments, 
the existence of a city budget surplusshaped the response to the epidemic. 

AIDS, like all disease, reflects social and cultural values. Implicit 
and explicit in the oral histories are evidence of stigma and homophobia, 
the politicization of the AIDS effort and those associated with it, and the 
tension between individual rights and social welfare. 

The foregoing themes are but a few of those inherent in these oral 
histories. I hope that scholars will be persuaded to explore these further 
and to discover and research those unmentioned. To serve as a rich, 
diverse, and unique source of information on multiple levels is after all 
a major purpose of this oral history series. 



Locations of the Oral Histories 

The oral history tapes and bound volumes are on deposit at The 
Bancroft Library. The volumes are also available at the National Library 
of Medicine, UCLA, and other manuscript libraries. 



Note Regarding Terminology 

In this series, both interviewer and interviewee occasionally use the 
term "AIDS" to refer to the disease before it had been officially given this 
name in the summer of 1982. "AIDS" is also used to refer to the disease 
which in recent years has come to be known in scientific and medical circles 
as "HIV disease." In these oral histories, the term "AIDS" has been 
retained, even when its use is not historically accurate, because it is the 
term with which readers are most familiar. 



Sally Smith Hughes, Ph.D. 
Project Director 

February 1, 1995 

Regional Oral History Office 

The Bancroft Library 

University of California, Berkeley 



LIST OF PARTICIPANTS IN THE SAN FRANCISCO AIDS ORAL HISTORY SERIES 



VOLUME I 

Selma K. Dritz, M.D., M.P.H, Epidemiologist, San Francisco Department of 

Public Health 
Mervyn F. Silverman, M.D., M.P.H., Director, San Francisco Department of 

Public Health 



AIDS Internist at San Francisco General Hospital 
Pediatric AIDS Physician and Administrator, UCSF 
AIDS Physician and Political Spokesman 
, D.Sc., Epidemiology and Virology at the Centers 



IN PROCESS 

Donald I. Abrams, M.D., 
Arthur J. Ammann, M.D. , 
Marcus A. Conant, M.D., 
Donald P. Francis, M.D. 

for Disease Control 

Deborah Greenspan, D.D.S., D.Sc., Oral Manifestations of AIDS 
John S. Greenspan, D.D.S., Ph.D., AIDS Specimen Bank, UCSF 
Jay A. Levy, M.D., Virologist, UCSF: Isolation of the AIDS Virus 
Andrew A. Moss, Ph.D., Epidemiologist at San Francisco General Hospital 
Merle A. Sande, M.D., AIDS Activities at San Francisco General Hospital 
Paul A. Volberding, M.D., AIDS Oncologist at San Francisco General Hospital 
Warren Winkelstein, Jr., M.D. , M.P.H.-, The San Francisco Men's Health Study, 

UC Berkeley 
Constance B. Wofsy, M.D., Authority on Pneumocystis carinii Pneumonia and 

Women with AIDS, San Francisco General Hospital 
John L. Ziegler, M.D., AIDS Oncologist at the Veterans Administration 

Medical Center, San Francisco 



Regional Oral History Office University of California 

The Bancroft Library Berkeley, California 



The San Francisco AIDS Oral History Series 



THE AIDS EPIDEMIC IN SAN FRANCISCO: THE MEDICAL RESPONSE, 1981-1984 

Volume I 

Selma K. Dritz, M.D, M.P.H. 
CHARTING THE EPIDEMIOLOGICAL COURSE OF AIDS, 1981- 198A 



Interviews Conducted by 

Sally Smith Hughes 

in 1992 



Copyright 1995 by The Regents of the University of California 




Selma K. Dritz, M.D., M.P.H., 1982 



Photography courtesy San Francisco Chronicle 



INTERVIEW HISTORY- -by Sally Smith Hughes 



This oral history with Selma K. Dritz, M.D., M.P.H., is the first in 
the San Francisco AIDS Oral History Series: The Medical Response, 1981- 
1984. Dr. Dritz was interviewed because she played a seminal role in the 
early years of the AIDS epidemic in San Francisco. As assistant director 
of the Bureau of Disease Control of the San Francisco Department of 
Public Health, she tracked cases of what by mid- 1982 was known as "AIDS," 
collaborated with the Centers for Disease Control and the University of 
California, San Francisco [UCSF] in helping to establish the etiology and 
epidemiology of the disease, and worked tirelessly to educate the gay and 
straight communities about AIDS recognition and prevention. She also 
tells of her long-standing working relationship with the gay community, 
ties which she utilized when the epidemic broke in San Francisco in the 
summer of 1981. She also talks about the commitment and confusion of the 
early days when various theories competed as the explanation for the 
devastating infectious diseases appearing in previously healthy young 
men. Her dedication to combating the epidemic and obvious sympathy for 
those tragically affected underlie the interviews. 

This oral history is also important as a reflection of the health 
department's role in the epidemic. Dr. Dritz and Dr. Mervyn Silverman, 
director of the department until his resignation in December 1984, are 
the two voices in this series representing it. Both address the 
department's official role as coordinator of San Francisco's medical 
response to the epidemic. Yet the content of the two interviews differs 
significantly. Dr. Silverman focussed on the controversy regarding the 
bathhouses as sources of AIDS transmission, a wrenching episode resulting 
in his decision in October 1984 to order them closed. 

Dr. Dritz 's account, while certainly not without conflict and strong 
opinion, is more one of collaboration and cooperation, at least at the 
local level. She describes the health department's interrelationships 
with a complex web of city, state, and national institutionsphysicians 
and epidemiologists at UCSF and San Francisco General Hospital, local 
hospitals and private practitioners, gay political organizations and City 
Hall, and, further afield, health officials in Oakland, Los Angeles, and 
at the Centers for Disease Control in Atlanta. She became visibly 
agitated while discussing the federal governments slow and inadequate 
response to funding needs for AIDS research and the crippling effect the 
delay had on epidemiological research in particular. 

Her agitation is reflected in her penciled annotations on the AIDS 
chronology I composed to assist the interviews. When she returned it, I 
found she had written at the top: "After reading these notes, perhaps 
you'll think I'm not sufficiently impartial for your project. I would 
understand." My response was--and isthat one strength of this oral 
history series is that it represents a range of perspectives, all 
necessarily subjective, all requiring assessment against other sources, 
but all contributing to a picture of why the response to AIDS in San 



Francisco evolved the way it did. Dr. Dritz's voice is essential to this 
history. 

Others have already indicated that they agree. In September 1993 
Dr. Dritz attended the Los Angeles premier of the television serial, "And 
the Band Played On." The celebration with Randy Shilts, author of the 
book on which the videodrama is based, and Lily Tomlin, who portrayed Dr. 
Dritz, was tempered by forewarning of Shilts' death to AIDS five months 
later on February 17, 1984. 



The Oral History Process 

Four interview sessions were conducted with Dr. Dritz in June and 
July 1992. The setting was her modest home near the San Francisco Zoo 
where she has lived since 1949 and raised three children. The living 
room contains the grand piano testifying to her reputation as a near- 
concert level pianist. A more recent interest in clay sculpture is 
relegated to a portion of her basement. 

Our preliminary meeting on June 9, 1992 set the stage for the 
subsequent recording sessions: coffee at the kitchen table, documents 
within ready reach in the file cabinet in the adjoining room, animated 
conversation with this engaged and engaging woman. 

At Dr. Dritz's suggestion, I brought a projector to the second 
session so that she could show slides used in past AIDS talks. With me, 
she used them as starting points to describe her role and that of the 
health department as AIDS cases in the city escalated. The meticulous 
records which she kept were destroyed after she retired from the health 
department in 1984. Her oral history stands as a partial corrective to 
this loss of historical documentation. 

Feisty, alert, and looking far younger than her seventy- five years, 
she spoke forthrightly and at times passionately of the turbulent period 
when the cause of the epidemic and its transmission patterns were being 
worked out. (Dr. Dritz's retirement occurred in the same month as the 
announcement of the discovery of the AIDS virus, in April 1984.) The 
edited transcripts of the interviews were mailed to Dr. Dritz, who edited 
them lightly. The finished product not only describes the contributions 
of a key figure in the medical response to the AIDS epidemic, but also 
provides glimpses of an efficient and experienced epidemiologist and a 
compassionate human being. 

Sally Smith Hughes 
Interviewer /Project Director 

September 1994 

Regional Oral History Office 

The Bancroft Library 

University of California, Berkeley 



Regional Oral History Office 
Room 486 The Bancroft Library 



University of California 
Berkeley, California 94720 



BIOGRAPHICAL INFORMATION 
(Please write clearly. Use black ink.) 



Your full name 



Date of birth 



Birthplace 



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Father's full name 
Occupation 



Birthplace 



Mother's full name 

Occupation 
Your spouse 



Birthplace 



Occupation 



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Birthplace 



Your children 






Ht'ttiA. 

/ 



Where did you grow up? 
Present comraunity_ 
Education 



tti, t-\ . 



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Occupation(s) 



Areas of expertise 



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Other interests or activities 



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Organizations in which you are active 



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I EDUCATION AND EARLY CAREER 



[Interview 1: June 24, 1992] 



Education 



Hughes: Please tell me where you were born and educated. 

Dritz: I'm a middle westerner, born In Chicago [June 29, 1917], parents 
of Russian origin. Medical school, class of 1941, University of 
Illinois College of Medicine. Intern at Cook County Hospital 
[1941-1942]. Pediatrics residency at Cook County Hospital [1942- 
1944], all in Chicago. Chief resident of the Cook County 
Contagious Disease Hospital. 



Early Career 



Pre-San Francisco 



Dritz: Then private practice in pediatrics, Gold Coast practice, if you 
please, in Chicago, during World War II. Then two years as 
pediatric consultant to the Illinois State Health Department 
[1946-1947], retired at that time to raise my children. I had 
been married during my residency. Came to San Francisco, remained 
retired until my children were In their mid- teens. Went to the 
School of Public Health at UC Berkeley, took a master's in '67 in 
public health. 



ended. 



This symbol Indicates that a tape or tape segment has begun or 
A guide to the tapes follows the transcript. 



I immediately joined the San Francisco health department In 
'67 and worked there until '84 as Assistant Director of Disease 
Control, in charge of all infectious disease epidemiology except 
classic venereal disease- -now we call it sexually transmitted 
disease- -and tuberculosis. Those were two separate-standing 
clinics . 

The work in infectious disease at first was the usual 
standard chasing down of measles, mumps, whooping cough, making 
sure that children in school had their proper immunizations, 
tracing down an occasional outbreak. For a time, I did 
occupational health, too, and industrial safety for the department 
[as chief of the Division of Occupational Health] . Then I was 
asked to take purely infectious disease as the city population 
grew and as new disease outbreaks appeared, particularly in our 
increasing population influx from the Pacific Rim. 

[tape interruption] 

Hughes: Why did you leave private practice? 

Dritz: My husband came back from overseas service in the navy in World 
War II, and we realized that this was the time that we wanted to 
start to raise a family. We had delayed for five years during the 
war in order to be sure that our children would not find that they 
were suddenly growing up without a father. So I retired. It 
worked out quite well. I felt that, as a pediatrician, I had a 
duty to other people's children, but my children had only one 
mother. There were other pediatricians for other people's 
children, so I stayed home and took care of my own children. 

Hughes: Did you like private practice in pediatrics? 

Dritz: It was interesting at that time, but by the time I was ready to 
come back to pediatrics, it was no longer of interest to me as 
such. In the early years, we were still challenged with polio. 
We didn't have a vaccine for polio; we didn't have the MMR 
[measles, mumps, and rubella] vaccines. It was a real challenge 
to take care of children. 

By the time I came back, most of those diseases had been 
relatively conquered, and the main interest was in neonatology-- 
treatment of premature infants- -whom I had cared for when I ran 
the preemie service at Cook County Hospital in pediatrics. But 
neonatology as such I didn't find too fascinating. The other 
aspect of pediatrics then was diseases and emotional problems of 
adolescence, and that too just wasn't what I wanted. 



A third factor was the fact that San Francisco, by the time I 
was ready to go out into private practice, was a different city. 
If I had to go out on a call at night alone in Chicago, I had 
driven with a heavy monkey wrench on the seat next to me. Now, 
since my husband was also a physician and we might both be out of 
the house at the same time at night, it just didn't do. 

So when I had my master's in public health, I joined the 
health department here. I could have an eight-to-five job, 
unquote- -it ran more than that- -but I could be assured that I 
would not be out when my children were at home at night. 

Hughes: Was that the main motivation for the master's in public health? 

Dritz: No. I had been pediatric consultant to the state health 

department in Illinois before I retired, and I found that it was 
the public health aspects of the work that were more interesting 
than the actual clinical aspects. In clinical medicine, I could 
help one patient at a time. Two patients at a time. Maybe even 
save a life. We didn't save them too often. But in public 
health, I could affect the health of many people at the same time. 
So I found that much more absorbing, and that was why I went for 
my master's in public health. 

Hughes: Is there anything you care to say about the program in public 
health? 

Dritz: It was a good program, but most of what I learned about public 

health, I learned on the job. You learn theoretically in a school 
of public health how to draw up a budget; you learn theoretically 
how to do health education, as two examples. Out here, when you 
do public health education, you have to first find yourself an 
interpreter for Korean, Tagalog, Vietnamese, Thai languages. You 
have to learn how you speak to people of other cultures without 
insulting them. You have to learn to think of diseases like, say, 
clonorchiasis- -Chinese liver fluke disease- -which you didn't see 
in San Francisco, but you see it now; people come in from the 
China Sea. 

You have to learn on the job how to write a budget, not 
according to the books , but according to how much you think you 
can get away with now, and still leave yourself an opening to go 
for a supplemental budget six months from now when what you're 
getting now isn't going to be enough and you know it isn't going 
to be enough, but you can't say it isn't going to be enough. 



Epidemiologist, San Francisco Department of Public Health, 
1967-1984 



Dritz: So I learned on the job. I learned that a good deal of public 
health--! suppose a good deal of most city occupations --is 
political. And in seventeen years on the job, I guess I must have 
been a pretty good politician, because I survived until I retired. 

Hughes: Is public health chronically underfunded? 

Dritz: Almost every department in this city is underfunded now, because 
the tax base is too low. The city has roughly 720,000 people 
here. Only about half of them really pay taxes. The big 
businesses pay taxes, I suppose, but they have lots and lots of 
write-offs. Maybe a third of the population is under the poverty 
level. There just isn't enough money, especially as new 
immigrants come in from the Pacific Rim and from Mexico. We have 
more Hispanic people from Guatemala and Colombia than we have from 
Mexico per se. That's different than Los Angeles. 

Immigrants are hindered by their poverty level, their 
language difficulties, and their educational lacks for the kind of 
service jobs we have here, where they can't run a computer and 
they can't handle typewriters. Men are eager to work but they're 
often just not qualified for the kinds of jobs we have. Older men 
now of the immigrant type are taking jobs at places like 
McDonald's at minimum salary simply to get food for people. 

Now, in San Francisco real estate is up; rents are enormous . 
I think next to New York, it's the most expensive city to live in. 
When you have a large population of below-poverty-level people, 
and rent and food and housing and everything else that you can 
think of is so terribly expensive, there are great lacks that 
welfare and mental health and injection drug services and health 
and Medicare all have to supply. There just isn't enough dollar 
pie to go around. In the health department, you were always 
fighting for a bigger slice of the pie. It was interesting. 

Hughes: Was Mervyn Silverman director when you first joined the 
department? 

Dritz: No, Ellis Sox was director when I was there for the first year or 
two. After he left, Francis Curry, who had been chief of the TB 
clinic, became director. About seven years later, must have been 
about '76 or '77 [1977], Mervyn Silverman became director after 
Frank Curry reached retirement age. We still had a sixty- five 
year retirement age then. 



Hughes: Were there policy shifts every time a new director came in? 

Dritz: Under Ellis Sox, everything was sort of free and easy. If there 
was a problem, you went in to talk with him about it, and he said, 
"Well, what do you want to do about it?" And that was it. You 
could do what you felt you wanted to do about it. 

Frank Curry was a good, conscientious health director. I 
think his major interest was in the TB group in the Chinese 
community because he had run the TB clinic. But he was fair and 
he knew his business. He was highly respected. 

Merv Silver-man was more an organization man. He knew 
contracts; he knew management. He was very, very interested and 
devoted to the public health and to getting services, and he knew 
how to get that aspect of the work done through good health 
officers under his direction. I would have liked to see him 
continue; he was a good man, but he got caught in that awful can 
of worms of the battle between the gays and the City Hall and the 
bathhouse owners. Nobody could have survived that. 

Hughes: Did he give you free rein when it came to the AIDS crisis? 

Dritz: Yes. Well, we had an AIDS advisory council [Medical Advisory 

Committee on AIDS, San Francisco Department of Public Health). I 
have a chart on that from the health department staff. San 
Francisco General, University of California at San Francisco, Bay 
Area Physicians for Human Rights, and several other groups: we 
all met regularly to discuss major problems and try to come to 
some consensus on how to handle them. Silverman was ready to 
listen to everybody. He asked very, very good questions, and then 
he made up his own mind. But it always seemed to be a pretty fair 
approach to the various views that had been presented. 

The work in AIDS was very difficult because we didn't know 
where we were going. We were blind people in a dark room, and if 
we had seen the light, we didn't know if we would recognize it. 



Enteric Disease in the Gay Community 



Hughes: Well, maybe before we actually get into AIDS per se, we should 
talk about the work that you had done with the gay community on 
enteric diseases. I think that sets the stage, both in terms of 
some of the disease patterns, and also in establishing your 
relationship with the gay community. 



Dritz: It certainly did. Back in '74, the board of supervisors in the 

city, under what pressure I don't know, ruled that acts in private 
between consenting adults were no affair of the police. That 
meant that there would be no more raids on baths, bars --there 
really weren't too many in the way of baths at that time. The 
action was in the back rooms of the bookstores, the back rooms of 
the bars, out in the bushes of Buena Vista Park when the weather 
permitted. 

With the passage .of that ordinance, the population of the gay 
community in San Francisco just exploded. Police had estimated 
that originally we might have between thirty and forty thousand 
gay men in the city--I just use the word gays; it's easier. By 
'75- '76- '77, they were estimating 120,000. People came from every 
city in the country where they were being harassed, from New York 
after the Stonewall battle; from Moscow, Idaho- -the university was 
said to have a large gay group there; from Humboldt County, 
California; from Texas; the cowboys out in Arizona and New Mexico 
who had to use what they called "tea rooms" for their contact, 
public bathrooms and so on, a lot of them came to San Francisco. 

Hughes: Was San Francisco unique in having that sort of an ordinance? 

Dritz: San Francisco was unique in a different way. It's a compact city. 
It's just fifty square miles; it's a square seven miles on each 
side. We can't spread anywhere without getting our feet wet, 
except down the peninsula, which is an enclave of mostly wealthy 
residential areas on the west, and some high crime and drugs on 
the Bayshore [Freeway] to the east. The compactness of the city 
made it possible for us in the health department, police 
department, fire department, to know practically everybody active 
there. Seven hundred thousand population. I think it dropped to 
about 680,000 at one time. 

Knowing the population there, knowing the neighborhoods, we 
were able to see that the Castro area and the Polk Street area 
north of that were developing more and more concentration of gay 
men. Now, for us it was simply a fact at that time, but for the 
gays it meant--I'm generalizing now, of course they could 
recognize each other more readily, they could make contacts more 
readily, and they didn't have to hide in a crowded bar or 
bookstore back room. They developed the baths. 

The baths were not so much places for swimming or washing 
yourself. They were large establishments. One of them, the Club 
Baths, was four stories high, I think. They had cubicles where 
the doors could be closed and where there was simply a bunk with a 
mattress and a jar of Crisco. There were also large what were 
called "orgy rooms," which were dark, a lot of music going on. It 



was possible for men to make contact with each other- -sexual 
contact, I mean now- -even standing up, without seeing each other's 
faces, and some of them actually told me later, "I don't know who 
he was. I never saw his face." I'm not trying to be funny about 
it, but these were places where a man could go in and make ten, 
fifteen, twenty contacts in the night, depending on how much 
energy he had. 

With that, we began to see an increase in diseases in the 
city. Not AIDS- -this was long before AIDS appeared. The VD 
clinic began to see much more syphilis and gonorrhea. Of course, 
that didn't bother anybody; one shot of penicillin and you were 
cured. And they began to be coming in with severe diarrheas. And 
then the reports began to come in from physicians in the 
community. See, by law, physicians were supposed to report all 
cases of enteric disease, diarrheal disease, shigella, amebiasis, 
salmonella- -almost any cause of diarrhea. This is because for the 
food processing and food serving industries, waiters, cooks had to 
be free of diarrheal disease. So any doctor who had a case of 
diarrheal disease in a man or a woman by law had to report it. 

We began having reports that were changing. Previously, let 
us say in '69, we would have reports of 100 cases in the course of 
a year, and they would be more or less evenly divided between 
males and females, and the age range would go from a few months of 
age to eighty -five years. 

By '76, '77, I was seeing a complete change. 1 For one thing, 
it went from 100 cases to 500 in the same period. It went from 
half-and-half male and female to- -on a sheet of twenty names, 
there would be eighteen males and two females. And the ages 
almost exclusively ranged between twenty- five and forty- five years 
of age. I looked again, and they were all shigella, either S. 
sonnei or later S. flexneri. But they were not just shigella. 
The cases were being reported by doctors who I knew had primarily 
gay patient populations, and by clinics that served a 
concentration of gay population. 

So we knew now that gay activities, the increasing gay 
population, the increasing gay contacts, and the baths, were 
contributing to transmission of a tremendous lot of enteric 
disease. Now, why enteric disease? Enteric means your guts, your 
stomach, intestines. And enteric disease ordinarily is a disease 
that is caused by swallowing the organism from contaminated food 
or contaminated water. 



1 See: S. K. Dritz. Medical aspects of homosexuality. New England 
Journal of Medicine 1980, 302:463-464. 



Now, these cases weren't coming from eating establishments. 
They were in men who were ingesting the bacteria or the hepatitis 
A virus in the oral -anal techniques that they were using for their 
gay sex contacts. As we developed more and more of these cases, 
we not only had an increase of hepatitis A, which is an 
enterically transmitted disease, but a lot of cases of hepatitis 
B. Now, that last shouldn't have happened, because hepatitis B 
has to be transmitted into the bloodstream, usually by a needle or 
a cut or a scratch, especially in a third- world country. 

Here, though, some of the traumatic anal techniques that the 
gays were using caused breaks in the mucosa and in the blood 
vessels in the anus and the rectum, and in the mouth, too, I 
suppose. And ingestion of fecal material from the anus of the 
passive partner into the mouth of the active partner produced 
hepatitis A; or injection of semen of the active partner into a 
broken blood vessel in the rectum of the passive partner with 
hepatitis B virus, meant that they were being injected 
parente rally. So we had a large increase in all of these 
diseases . 

Now, my job was to find out where these diseases were coming 
from, stop the source --that was a good job- -find out who had it, 
and make sure that they didn't pass it on to anyone else. So I 
did intensive interviews. I was able to reach about 70 percent of 
the shigella and hepatitis and amebiasis patients, by phone or in 
person or through interviews with their physicians. In almost 
every case, I found that it had to be oral-anal or anal-genital 
contact. 

But in investigating this, I had to make contact with members 
of the gay community, the officers of their various political 
clubs- -there was the Alice B. Toklas [Gay Democratic] Club, the 
Stonewall [Gay Democratic Club] , the Harvey Milk [Memorial 
Democratic] Club, the Tavern Guild, which was the association of 
gay bar managers and owners and try to pass on word to them how 
the gays were getting these diarrheas and the fact that we could 
cure them. But the next time they went out, they would catch them 
again, because there was no immunization for them then. 

Hughes: Were they receptive to your suggestions? 

Dritz: Many of them were, because they found that we were not being 

antagonistic or punitive. I tried to make it clear that my job 
was to stop the diseases, and I didn't care what they did in bed, 
in the bushes, or anywhere else. My job was simply to see that 
they didn't catch them again. I didn't want them to get sick. 
They responded to a sympathetic approach, maybe because they had 
so little of it; I don't know. 



The gay community found that the health department was 
helpful, that we wanted to be helpful, and the private doctors 
that were curing them- -treating then, anyhow- -told them that we 
were trying to help, too. 

As a matter of fact, once one of the doctors sent In reports 
from his private office lab that just didn't make sense at all. 
It looked like something was going crazy In the lab. I couldn't 
accept those reports, so I called the doctor and asked him, did he 
mind If we sent one of our lab technicians In? The city had the 
microbiology lab, the reference lab of the health department; we 
worked together all the time. I asked him if we could send In one 
of our technicians Just to review his lab technicians' work. He 
agreed. Our lab tech reported back they had big mistakes in what 
they were doing, and corrected it all, and my reports began to 
come through as they should be. The physician was very happy 
about it. 

A gay physician would call in perhaps and say, "I think I've 
got a Rocky Mountain spotted fever case. I just don't understand 
it." And I offered our lab as an additional check on his lab. We 
confirmed it. I called him back, I said, "Tom, that was a good 
diagnosis. It is Rocky Mountain spotted fever." He'd say, 
"Thanks a lot, Selma," that sort of thing. So we were on a one- 
to-one basis, a first-name basis, with many of the gay physicians. 
As a matter of fact, it bothers me now to know that seven of those 
that I knew have died of AIDS. They were good doctors, and there 
are still some really good ones practicing there. 

So I had rapport with the gay community, I had rapport with 
their political and social organizations, I had rapport with their 
doctors. Because they trusted us, they reported in, in spite of 
being afraid of the confidentiality problems. So we knew better 
what was happening, and how it was happening, why it was 
happening. Until AIDS hit us. And then we didn't know from 
beans . 



10 



II THE AIDS EPIDEMIC 



Early Cases of AIDS 



Kaposl's Sarcoma 



Hughes: When were you alerted to the fact that something unusual was 
happening in the gay community? 

Dritz: Actually, not in our gay community, but among the gay population 
in the country, the first thing was the publication of Michael 
Gottlieb's article in the MMWR. 1 It was in June of '81. 

[tape interruption] 

Dritz: We [in San Francisco] didn't get our first cases until late July, 
early August. Those were not cases of PneumocystLs [PCP] . The 
first one was a case of Kaposi's sarcoma [KS] reported by Dr. Jim 
Groundwater in a man called Ken Home. Jim was very excited about 
it, because we had already known that Kaposi's sarcoma was being 
reported from New York by Linda Laubenstein. Dr. Groundwater 
suspected that it must be part of this same outbreak. Ken Home 
lasted about two years, I think; that's all. 

After that first case, we had three or four other cases of 
Kaposi's in a row, within a week or two. Then we began to get a 
sprinkling of PneumocystLs pneumonia and Kaposi's sarcoma. By the 
end of the first month, we had a little over twenty cases, and two 
had already died. 



1 M. S. Gottlieb, H. M. Schanker, et al. PneumocystLs pneumonia --Los 
Angeles. Morbidity and Mortality Weekly Report 1981, 30:21, 250-251. (June 
5, 1981) 



11 



At this time, in our health department, we had a coordinating 
office for gay and lesbian health services. We met every week in 
the office of that group. Members of the various gay clubs, 
Tavern Guild, independent gays -- anybody who was interested- -came 
in. Each week, I would report to them how many more new cases 
there were, how many more new deaths. And it became ominous, week 
after week. I would tell them, "There were twenty-two cases; now 
there's a total of twenty- six cases; we have four deaths already." 

Patients at the time they were diagnosed had been sick a long 
time. They would come to the doctor after whatever they tried to 
do themselves for "these spots", unquote, on their skin, didn't 
work, and then doctors might use one ointment after another. 
Finally, they would take a biopsy. Now, some of the doctors did 
biopsies right away, but in general they would take a biopsy and 
it eventually came back with [the comment], "Good Lord! Kaposi's 
sarcoma! What's that doing here?" 

We knew then that Kaposi's sarcoma is a disease of old men in 
the Mediterranean littoral or in North Africa. Lesions on their 
lower limbs become ulcerous, perhaps after a few years, but 
they're slow-growing; they're indolent. The men last for eight, 
ten, twelve, fourteen years, until they die of something else. 
Unless they would get a terrible infection, such as septicemia, 
and die from that source, KS usually didn't kill them. 

These young men, though, were not Mediterranean old men. 
They had the lesions all over them, and internally, too. The 
lesions were working fast, and the men died in a few months. And 
we didn't even know if they were dying of the Kaposi's sarcoma, or 
something else. And we didn't even know they had the KS before 
the lesions showed up. We didn't know what caused it, except in 
Africa it was related we thought to the cytomegalovirus . So it 
was a great puzzle. Why is this African disease of old men 
suddenly appearing so virulently in San Francisco and New York in 
the gay community? It raised big questions. 



Pneumocystis carinii Pneumonia 

Dritz: Then the Pneumocystis organisms began to show up. Now, there it 
could easily be missed, and it probably was missed at first until 
we became aware that there was such a disease as an active 
Pneumocystis carinii pneumonia. Ordinarily this organism can be 
found in the lungs of some normally healthy people and it's just 
either living there in symbiosis or as the organisms come in 



12 



they're killed by our immune system responses. In this case, it 
caused a violent bronchopneumonia, and they died of the pneumonia. 

Now, first of all, we had to find out that it was 
Pneumocystis pneumonia. Then we had to find out how to treat it. 
Centers for Disease Control [CDC] had a drug called pentamidine, 
which they distributed to doctors at the doctors' request when the 
doctors sent in to CDC in Atlanta proof that they had a case of 
Pneumocystis pneumonia. 

Hughes: Why was the drug so carefully controlled? 

Dritz: It might have been very expensive; I don't know. It may have been 
to track presence of a very rare infection. CDC's prime job was 
infection control. 



Dritz: Those patients who needed pentamidine almost invariably had had a 

renal transplant or were on chemotherapy or on radiation for cancer-- 
kids with leukemia, persons whose immune systems had been depressed 
in order to keep them from rejecting the transplant. Without an 
immune system, the Pneumocystis could cause pneumonia. Two or three 
times a year, you'd have a case of Pneumocystis . Dr. [Oscar] 
Salvitierri up at the kidney transplant unit at UCSF reported a 
couple of cases like that. I had talked with him about it. 

Now, we were finding Pneumocystis in apparently normally 
healthy young men, twenty-five, thirty, forty years old. These 
people shouldn't be getting it. So we began wondering, was 
something wrong with their immune systems? But we didn't have any 
evidence . 

A paper on that came out sometime later, I think it was in 
the New England Journal of Medicine, proving that the T4 cells, 
what are now called the CD4 cells, the helper cells, are depressed 
below a critical level of 200 T cells/mm 3 in these patients. 1 A 
normal level for a healthy person is around 1000. When a person 
gets, let's say, severe pneumonia or flu, the immune system may be 
temporarily depressed a little bit. And as he recovers it rises 
again. 

We began to think that maybe these gay men, since they were 
getting one disease after another- - shigellosis , amebiasis, 



X H. Masur, M. A. Michelis et al. An outbreak of community- acquired 
Pneumocystis carinii pneumonia: Initial manifestation of cellular immune 
dysfunction. Nev England Journal of Medicine 1981, 305:1431-1438. 



13 



hepatitis A, hepatitis B, syphilis, gonorrhea, lymphogranuloma 
venereum, one after another and in rotation, perhaps their immune 
systems were finally being depressed to a critical level below 
which they couldn't recover any more. Therefore, maybe it was 
just these repeated infections that were making them susceptible 
to Pnewaocystis and Kaposi's sarcoma. We still didn't know what 
other reason there would be for their being susceptible to these 
diseases. We still didn't know about HIV [human immunodeficiency 
virus] . 



[tape interruption] 



Kaposi's Sarcoma Study Group and Clinic 



Hughes: The KS study group was organized in 1981. Do you remember exactly 
when? 

Dritz: Well, it must have been right after the first cases appeared [in 
the summer of 1981]. I remember Marcus Conant showing us in his 
clinic the skin lesions on the heel and leg of Bobbi Campbell, a 
male nurse, who was the first case of KS that we saw in the 
clinic. I had come in from the health department, and some of 
Conant' s residents, and some of the other doctors from dermatology 
and oncology were there, because this was such an interesting 
case. 

After that, we began to meet every week or every two weeks, I 
think on alternate Tuesdays, as a grand rounds clinic to look at 
cases and to talk about things. Among us there were those who 
really became the core of the AIDS activities: me, Conant, Don 
Abrams, who is now the director of the San Francisco County 
Community Consortium which conducts trial therapeutic tests for 
various medications for AIDS. (The consortium demonstrated that 
inhalation of pentamidine would help prevent recurrence of cases 
of Pneuoioc/stis pneumonia.) 

There was John Conte from the UCSF infectious disease unit, 
there was Dave Altman of gastroenterology at UCSF, Jim Groundwater 
of dermatology at UCSF, Paul Volberding of oncology-hematology at 
San Francisco General Hospital, Jay Levy from virology at UCSF. 
If I've forgotten anybody, I'm sorry. Oh, and Paul Dague. Paul 
Dague was a Ph.D., I think, and he was in psychology. He was 
very, very anxious to help. He did a lot of work with 
questionnaires on gay patients, and he was dead within a year 
[January 1984] . 



.tape Interruption] 



Simon Guzman: An Earlv Patient 



Drltz: One of the early patients was Simon Guzman, also a KS case. Now, 
he was characteristic of some of the patients who ran like crazy 
everywhere in the country and to Europe looking for a treatment, 
because the diagnosis was a sentence of death. Simon Guzman ran 
down to Mexico for therapy after Marc Conant diagnosed him, 
because the Mexicans were supposed to have drugs there that the 
Food and Drug Administration [FDA] wouldn't permit in the States. 

It didn't work on him. He went to the Philippines right from 
Mexico for a highly touted bloodless hands-on surgery, which of 
course did nothing for him. He came back in worse shape; had to 
be hospitalized. Marc Conant put him into UCSF, and we worked for 
eight solid months and $200,000 later, when he died. 

In the course of that, we learned a lot about AIDS, because 
his immune system went down just to nothing. He developed 
cytomegalovirus , he developed brain lymphoma, he developed 
PneusaocystLs pneumonia, he developed cryptosporidiosis. Gallons 
and gallons of fluid poured out with the diarrhea. There was 
nothing we could do. We couldn't stop It. We gave what we call 
purely supportive therapy: Treat the symptoms. After eight 
months, he died. It was a pity that he lived that long, because 
he suffered. 

This was the kind of thing that happened, and this was the 
kind of thing from which we learned. We learned what didn't work, 
not what worked. 

Hughes: Were you thinking about a compromised immune system? 

Dritz: When we had Pneumocystis pneumonia showing up, we had to think, 

"Maybe there's something wrong with their immune system," because 
we found that disease only in people whose immune systems had been 
deliberately suppressed for other reasons. 

Hughes: So that was an idea that occurred to you-- 

Dritz: It was an Idea, but we couldn't follow up on It. In the meantime, 
researchers were working on it back East, and it eventually came 
out in the literature. 



15 



Investigating the Etiology of AIDS 



Possible Causes 



Dritz: We were beginning to think, well, you suppress the immune system 
either by radiation or chemotherapy. Maybe some chemicals in the 
gay community are suppressing the immune system. So we began to 
look at the environment. All the gays generalizing, of course- - 
had plants in their house. What do you use on your plants? Plant 
food, plant chemicals, bug sprays. They all had dogs or cats or 
something. What do you use on your pets? What do you use to get 
a high? We sent two of my men into the Jaguar Bookstore and the 
Ambush, and they bought "poppers" under the counter. We sent them 
down to CDC in Atlanta and let CDC analyze them. 

There's another part to that, too. The poppers turned out to 
be nitrites, but we found that almost all the gays were using the 
poppers. Why didn't all of them get this disease? Why did only a 
few? We didn't know at that time that most of them were already 
infected with it, because we didn't have a test for it. Why 
aren't they sick? So there was that question. 



The CDC Questionnaire 



Dritz: As we got to the point where we had about 100 patients, CDC worked 
out for us about a twenty- four page questionnaire that covered 
everything: Where were you born, where were your parents born, 
what do you do- -all the lifestyle factors- -what techniques of 
sexual communication do you use, what do you use in your house, 
what do you use in the way of drugs? Have you ever traveled? Did 
you serve in the armed services? Where did you serve, and what 
kind of materials do you use in your occupation? What are your 
hobbies, and do you use airplane glue? Everything we could think 
of. 

Hughes: Was that questionnaire based on earlier questionnaires, or was it 
created for the AIDS epidemic? 

Dritz: No, we put that together- -it was creative. CDC called us down 

there to Atlanta. I was from San Francisco, there were two from 
New York, one from Texas, I believe, and I think one from Chicago. 

Hughes: These were all public health people? 



16 



Dritz: Yes. 

Hughes: Do you remember any names? 

Dritz: No, I'm sorry. But Jim Curran and Harold Jaffe were there for 
CDC. I think maybe Bill Darrow, too. We did actual role- 
modeling, role-playing, with this questionnaire, to see how it 
would be used and how useful it might be, and where it might 
antagonize the person who is being interrogated. 

I used the questionnaire on about 100 of the patients here. 
It took almost two hours to go through it in detail with each one. 
We gathered all the information and sent it all back to CDC, and 
it took them two years to do a computer analysis of it, twenty- 
four pages of questions. It took them about a year and a half to 
get budget enough to hire another statistician to do the job. Jim 
Curran was crazy; he was wild: NIH [National Institutes of 
Health] wouldn't give him the money. 

See, the government wouldn't give CDC extra money. If they 
needed more money, it had to come from some other health 
department [Health and Human Services] budget. NIH also had not 
only NIAID, National Institute of Allergy and Infectious Diseases, 
but they also had the National Cancer Institute, and the other 
institutes. So to get money for the special AIDS project of CDC, 
they had to take it from somewhere else. Nobody else was going to 
give it up. 

Hughes: I can imagine. 

Dritz: When CDC finally got the money almost two years later for a 

statistician to analyze the questionnaires when we knew already 
that this had to be an infectious disease, they said, "The only 
thing that adds up here, the only thing that is significant, is 
type of sexual activity and amount of sexual activity." That was 
it. The poppers didn't come through, dog sprays didn't come 
through, food didn't come through, travel didn't come through. 
Even the previous diseases gays had- -they all had those diseases. 
But the one thing that came through was the sexual- -some person 
might use the word- -promiscuity. It's as descriptive as anything 
else. But when a gay man reported three times a week, ten 
contacts each time in the baths or something like that, it's 
pretty active, if not promiscuous. 

Now, some of them had quiet, monogamous relationships with 
monogamous partners, and they were closeted, and we didn't know 
about them. But those who were out, who called themselves the 
"Castro Clones," the very young, very slender, short haircut, 
moustache, tight jeans --the clothing stores on Polk Street didn't 



17 



carry a waistline in jeans bigger than twenty-four inches (mine is 
bigger than that) --they were the ones that were really out in the 
baths in force, night after night. 



Suspicions of a Transmissible Agent 



Dritz: Now, when you have so many people in close contact, so easily 
visible to each other, and the police aren't bothering you, 
there's a lot of [sexual] activity. If you have a transmissible 
disease, that's where it's going to be transmitted. We had proved 
that gays transmit the enteric diseases, so we were beginning to 
be almost certain that with this, too, we had a transmissible 
disease. 

Hughes: How early do you think you could say that? 

Dritz: Well, by the end of '82 we had the case of the baby at UCSF 

infected through a blood transfusion. That was sort of the nail 
in the coffin, as far as we were concerned, as proof that AIDS was 
a blood- transmissible disease. We didn't know what was being 
transmitted yet, but we knew something was being transmitted. 



Diagnosing AIDS 

[Interview 2: June 29, 1992] 



Hughes: Dr. Dritz, I thought we should start with the changing definitions 
of HIV disease as the epidemic progressed. Could you start with 
how you were defining the disease in the very earliest days? 

Dritz: The earliest cases were a series of Kaposi's sarcomas. They 

weren't diagnosed very quickly either, because we weren't looking 
for KS in young people in this part of the world. When cases of 
Pneuaocystis appeared in San Francisco a little bit after Michael 
Gottlieb's report in CDC's Mortality and Morbidity Weekly Report, 
we realized that there must be some kind of connection between the 
two outbreaks. We were calling it simply "gay cancer," "gay 
pneumonia." The gay community objected to the "gay" label, of 
course, and we tried simply to call it pneumonia in members of the 
gay community. Later, gay patients preferred to call themselves 
"PWAs" or "Persons with AIDS." 



18 



After a while, though, we began to see other diseases beside 
the pneumonia and KS that we lumped under the terms "01 , " 
opportunistic infections. We had cases of non-Hodgkins lymphoma. 
That was a very rare thing. It was DUNHL-- diffuse 
undifferentiated non-Hodgkins lymphoma- -massive increase in the 
size and inflammatory processes in the lymph glands. It was a 
lymphoma, it was a cancer, and it was appearing in the same 
population. 

Then, we began to see in the next year Burkitt's lymphoma, 
which is an African lymphoma, which is the most virulent of them 
all with a doubling rate of twenty-four hours, seen usually in 
young boys in central Africa and related to the Epstein-Barr 
virus. So here again, we were looking for viruses. The cancer 
registry told us when we asked that they could expect two or three 
cases of Burkitt's lymphoma diagnosed in the course of maybe two 
years, in all of California. And we had eight cases in the course 
of nine months here. So Burkitt's lymphoma became part of our 
local diagnosis of AIDS. 1 

It wasn't until quite a good deal later that we got reports 
from the laboratories of bone marrow analyses that showed 
Hycobacterium avium, sort of related to tuberculosis but in the 
bone marrow, in young children and infants born of AIDS-infected 
mothers. 

We began to see oral candidiasis. Francine Lozada, one of 
the professors in the [UCSF] dental school, diagnosed that for 
us. 2 Candidiasis- -thrush--is a fungus, a yeast, in the mouth. 
It would grow down into the esophagus. It would get all the way 
into the intestinal tract. The patients had it in their rectum, 
the anus- -horrible thing. 

In the same type of patients- -young, gay men- -Francine was 
able to show us, and I have pictures of it, Kaposi's sarcoma 
behind the teeth in the mouths that were already infected with the 
candidiasis. We had a new diagnosis there. Then she found hairy 
leukoplakia--very rare. 3 It was a very zoo of infectious 



*For more on the AIDS -lymphoma association, see the oral history in 
this series with John L. Ziegler. 

2 F. Lozada, S. Silverman, Jr., et al. New outbreak of oral tumors, 
malignancies and infectious diseases strikes young male homosexuals. 
California Dental Association Journal 1982, March, 39-42. 

3 For more on hairy leukoplakia, see the oral histories in this series 
with Deborah and John S. Greenspan. 



19 



that do not cause serious disease generally in healthy persons 
with normal immune response. 

We found in taking histories of these infected men that a lot 
of them had had herpes zoster- -shingles- -perhaps six months before 
their AIDS symptoms began to develop, before they were "sick" --the 
most devastating, damaging, herpes zoster that one could imagine. 
Now, herpes zoster is caused by the varicella virus, that is, the 
chicken pox virus, which many adults apparently seem to harbor 
quiescently in the neural ganglia. For some reason in some, 
usually elderly, people, it's activatedwe don't know why--and 
causes shingles, following the nerve trunk on the chest or on the 
head. It doesn't happen in young men to the degree that we saw 
it. So this again became part of our diagnosis. 

Then there were the violent diarrheas that were finally 
diagnosed in Simon Guzman as a cryptosporidiosis , a parasitic 
disease of sheep and goats. And we found later that sheepherders 
when they're tested are found to have antibodies to this disease. 
They've had it, but they didn't get sick with it. They hadn't any 
diarrhea; they didn't even know they had it. But these patients 
were pouring out two, three, four liters of fluid in twenty- four 
hours. So we had another diagnosis. 

I could go down the whole list. There was PML- -progressive 
multifocal leukoencephalopathy. It was another lymph gland 
problem, to put it very briefly. T cells they're called T cells 
because they're produced in the thymus--act against invading 
organisms. The T cells are one part of the immune complex. But 
there were B cells, too. They're the cells that develop in the 
bone marrow and seem to proliferate in the lymph nodes. We saw 
later that when the lymph nodes became inflamed with AIDS virus, 
there was an overgrowth of B cells, and then they all died down. 

Now, the B cells produce the circulating antibodies. Instead 
of attacking the invading organisms directly like the T cells do, 
they throw out antibodies to neutralize the chemicals in the 
virus. Except the virus was secreted in the white cells of the 
blood, and the antibodies couldn't reach it. That's why we 
thought, although we found high levels of HIV antibodies in the 
gay men, that they were still infected, and they still got sick, 
because the antibodies couldn't reach the virus. 

Incidentally, a little aside is that an ordinary vaccine is 
actually a synthetic antibody to an invading organism, whether it 
is a bacterium or a virus or whatever. The antibody chemically 
hooks on to the invading organism. When it chemically hooks on to 
it, the two become a different chemical, a third chemical, and 
that third chemical doesn't cause the damage in the body. 



20 



But you couldn't use an antibody, or a vaccine if you wish, 
that would attack the HIV, even if we had one then, because it 
would have to get into the cell where the HIV is already secreted, 
which would destroy the cell, which we don't want to do. So what 
we're trying to do now is to find something that will inter fere- - 
AZT may do it to some degree, except it has side effectswith the 
reverse transcriptase enzyme which the virus needs to take over 
the mechanism within the cell to duplicate its own DNA at the 
expense of the cell's DNA. 

I got off the track a little- -but all of these various 
infections and damages to various parts of the body became part of 
our picture of what AIDS was, but it developed gradually. For a 
couple of weeks, it was only KS, and then PCP, and then later on 
we got more and more opportunistic infections, and the horror of 
the thing grew week by week. 



Recognizing Immune Suppression 

Hughes: At what stage did it become clear to you and others that there was 
an underlying immune problem? 

Dritz: There was a publication in the New England Journal of Medicine 

which indicated that the T cells were way down in AIDS patients. 1 
Now, before that, there was no good way to count and differentiate 
helper cells, the T4 cells, from the T8 cells, the suppressor 
cells --they 're now called CD4 and CDS, or C4 and C8. 

Since the lymph glands were involved in all these cases- -a 
lot of patients had lymphadenopathy before they showed the other 
illnesses- -the cells of the lymph glands were studied carefully. 
We found that the T4 cells are diminished. An ordinary healthy 
person would have, let us say, 900 cells/mm 3 . In a person who has 
recently been quite ill, it might be down to 800, 700, 600, and it 
would recover in time. 

In gay people, it went down below 500 cells, below 400, and 
approached 200 when they were actively showing symptoms of AIDS- 
complicating diseases. So then we knew that something was 
attacking the T cells, destroying them in the most severe cases to 
the point that we couldn't count them any more. 



*H. Masur et al. Op. cit. 



21 



More on Etiology 



Dritz: Now, we knew then that we had to find some way to prevent this 

from happening, and In order to prevent It, we had to get Into the 
cells. We didn't have the virus yet. However, knowing that the T 
cells were being destroyed, we couldn't rule out some chemical 
toxin which also destroys the cells. We couldn't rule out some 
previously unknown mechanism within the humoral system, the blood 
system. We couldn't rule out some new invader. We had ruled out 
every invader that we could test for, which didn't mean that we 
had ruled out every invader. 

Hughes: You mean micro-organisms and viruses? 

Dritz: Yes. An animal or plant life form- -a yeast is a plant form-- 
rather than an inert chemical toxin, which could also destroy 
things, but not as a living form. So we still didn't know. We 
were looking for chemicals in the environment, chemicals used in 
their occupation, chemicals used in their hobbies. People were 
sniffing glue, and they used airplane glue and so on. 

A normal sexually active adult heterosexual male maybe would 
report as many as twenty- five heterosexual contacts per year. The 
gays could average sixty-five per year, and as high as 3,500 in a 
lifetime (and those lives were short!). We were looking at sexual 
stimulants- -poppers- -and the other chemicals they used. Poppers 
are amyl nitrites. We were thinking about what kind of sexual 
lubricants they used, whether on the penis or in the rectum, and 
the various chemicals which might have some effect if they were 
getting into the bloodstream through broken blood vessels in the 
anus. A lot of gays were using steroids to build up their 
muscles, and we do know that steroids do have a deleterious effect 
on the immune system. 

Hughes: They're immune -suppressant. 

Dritz: Yes. Then, besides chemicals, we were looking for a genetic 

factor. Why did some men get this virus and get sick quickly? 
Why did other men apparently remain immune? Now, they were 
infected, but we didn't know it yet. So why did they remain 
"immune?" Dr. Alvin Friedman-Kien in New York was testing the 
genetic factor, HLA-DR5. He thought he found, in the gay men he 
tested, statistically significant numbers who had some deficiency 
in their HLA-DR5, but eventually that wasn't confirmed by anybody 
else, and he dropped it. You must remember, much of the 
heterosexual population who were homophobic, if you wish, said 
that "there's something wrong with gays' genes; they're born 



wrong . 
at. 



22 



So this genetic factor of Friedman-Kien had to be looked 



I told you that gay men had so many serial infections- - 
sexually transmitted diseases, enteric diseases any or all of 
which could depress their immune response. If they infections in 
rapid succession, it could be that the immune system never got 
back up to anywhere near normal before it was knocked down again. 
It could have been depressed below a critical level to the degree 
that it couldn't recover at all any more. 

At that point, maybe whatever agency destroyed their immune 
response left them vulnerable to any invader that found them. We 
thought at that time that their serial infections must have been 
that agency. 

Hughes: To put it colloquially, the straw that broke the camel's back. 

Dritz: That's right. Then we were looking at bacteria, but everything we 
checked was negative. We looked at fungi and yeasts. Now, 
candidiasis is caused by a yeast, and some of the other AIDS 
infections are caused by a yeast. We looked at protozoa. PCP is 
caused by a relative of protozoa. We looked at parasites. A lot 
of them had round worms- -Ascaris- -surprisingly, which we don't see 
in this country unless somebody's come back from Mexico or perhaps 
an ashram in India. We worried about this. 

And then the viruses, finally. We couldn't look at viruses 
without an electron microscope; the other bacteria and parasites 
we could inspect under a standard light microscope. Of all the 
viruses we could and did test for by biological methods, the 
herpes group was of most interest, because herpes zoster is one of 
the herpes group, cytomegalovirus [CMV] is the herpes group, 
Epstein-Barr virus [EBV] is the herpes group. EBV is related to 
Burkitt's lymphoma, and causes mononucleosis in he States. CMV is 
related to Kaposi's sarcoma in Africa. Both conditions are forms 
of cancer. Would solving this mystery bring us closer to an 
attack on the cancer problem, too? 



Retrovirologv 



Dritz: Then we were looking for the HTLV, human T cell lymphotropic 
virus. 

Hughes: Because of Robert Gallo's work? 



23 



Dritz: Gallo had previously reported identifying HTLV-1. It was the 

first time that a virus had been proved to be the cause of a human 
cancer. Now, that was HTLV-1. Before that, we knew tobacco 
mosaic virus was the cause of a tobacco plant tumor. Chicken 
sarcoma is caused by an identified virus. This was the first time 
that a human cancer, adult leukemia, was proved to be caused by a 
virus- -a retrovirus. He deserves greatest credit for his 
discovery. This, though, didn't help us with AIDS, since the 
adult leukemia he had found was localized in a small area of 
southwestern Japan. There was no AIDS reported there. 

Then Gallo identified HTLV-II, and Murray Gardner at the 
Primate Research Center at UC Davis found a monkey- -it was a 
Macacus rhesus- -that had the equivalent of human AIDS. He didn't 
find the virus, but he was able to prove by shifting monkeys from 
one cage to another and permitting the air to go from one 
direction to another- -things that you can't do with humans --that 
it was a transmissible disease, that it had to be transmissible 
monkey -to -monkey, and that it didn't transmit through the air or 
through the food dish, but through cuts and scratches in fights. 
I don't remember if he did or didn't prove that infected female 
monkeys gave birth to infected infant monkeys. But he proved that 
this simian AIDS, if it truly was an AIDS like the human AIDS, was 
a transmissible disease. [Myron] Max Essex reported similar 
findings from Harvard University's primate research center. That 
was very exciting. 

Hughes: It also provided an animal model, didn't it? 

Dritz: No, it didn't, because it's only recently that we've found a 
monkey- -just in the last few weeks, I think it is --that can 
develop true AIDS. 

Hughes : The macaque . 

Dritz: That's right. There are varieties of macaque. Until that 

discovery, only the chimpanzee was known to develop true AIDS. 
Jay Levy said he'd love to test it out, but $50,000 to purchase a 
chimpanzee? 

Hughes: Wow! 

Dritz: Somebody else said, "No, it's $15,000." 

Hughes: A bargain. 

Dritz: Yes. And there aren't that many. Of course, the animal rights 

people would have a very valid argument, too. People would raise 
fewer objections about macaques because there are so many more of 



24 



Hughes : 
Dritz: 

Hughes : 
Dritz: 



them, and they're not quite so closely related to humans. I'm not 
anti- animal rights, of course. Animals should be treated 
decently, sympathetically, humanely. But I still place human life 
at a higher level of priority than animals'. Somebody's going to 
throw a rock through my window for this. 

Then the herpes group was out as a primary cause of AIDS, and 
the HTLV group we couldn't prove anything. Every new virus had 
come from Africa in the last half -century anyway: Lassa virus, 
African green monkey disease, Marburg virus, Eboli River virus- - 
there may have been one or two others. And then African swine 
fever, which was found in Haiti. Since AIDS was found in Haiti, 
the question was raised, maybe it's caused by the African swine 
fever virus. Couldn't prove it. I don't know how many more 
viruses we considered. We probably had the virus of the week or 
the virus of the month. 

So between all of these things, we had our own definition of 
AIDS that didn't fit exactly with CDC's. 

Now, when you say "our," do you mean the health department? 

Our office here, yes. I was tabulating Burkitt's lymphoma as 
cases of AIDS in late '82. CDC didn't accept that until months 
later. 

With other parameters? Burkitt's would have to be in young men to 
be classified as AIDS, wouldn't it? 

Well, my cases were. It was Burkitt's lymphoma, but they had the 
weight loss and the fever and the night sweats and everything else 
[characteristic of AIDS]. They had that history before all of the 
more definitive symptoms of AIDS appeared. 

Warren Winkelstein's group's ongoing study 1 on San Francisco 
gay men found that if they went back a few years before the men 
they were interviewing had become overtly sick, they found, yes, a 
couple of months ago the men had what they thought was flu, but 
got over it, and maybe two months later they began to lose weight 
and so on. 



San Francisco Men's Health Study. For more on this study, see 
the oral history in this series with Dr. Winkelstein. 



25 



AIDS Progression 



Dritz: Winkelstein's group finally characterized the disease. AIDS 

starts with an Invasion almost like flu, and then you get well for 
a while, and then you begin to lose a little weight, and your 
lymph glands flare up, and then your lymph glands go down after a 
while, and you seem to be all right. That Is ominous, we found 
later, because after the lymph glands die down, then a short time 
later, patients develop overt AIDS with one or another or a 
combination of the opportunistic infections. 

Hughes: And the T-cell count is dropping all the time. 

Dritz: That's right. Well, we learned to count the T cells, too, and 

that was finally part of our definition. Our lab had difficulty; 
it's a complex procedure and requires specialized equipment, which 
was just then becoming available to researchers, and we couldn't 
afford it in San Francisco then. 

The first time the cell sorter was available was down at 
Stanford, I think. The Stanford group was using that equipment, 
on loan from one of the manufacturing companies [Beckton 
Dickinson], I believe. I didn't do any lab work myself; I knew 
what they were doing. I may have some details wrong here. 

Hughes: Well, at this early stage, were you working under the assumption 
that this was a disease of gays? 



Risk Groups 



Dritz: No. We were working under the assumption that this was a disease 
that required multiple intimate contacts, by any persons, and it 
apparently had to be something that could get into the circulatory 
system. So it wasn't necessarily only gays. Now, the first few 
months, half-year maybe, we didn't even think in terms of 
intravenous drug users, but after a while, we realized that it 
didn't have to be gays only. Anybody who had unclean infected 
material introduced into the circulatory system from any source 
whatever, whether it be an IV needle from a drug user or the semen 
of an infected man going through the anus of a passive partner, 
any of these kinds of people could catch It. 

And then, after we had the hemophiliacs being diagnosed with 
the disease and getting very sick very rapidly, we realized that 
it had to be something injected into the bloodstream. 



26 



Hughes: Well, the CDC, reported the first cases in heterosexuals in August 
1981. * 

Dritz: They also knew AIDS had to be sexually transmitted when CDC 
reported that a hemophiliac's wife was now infected with the 
disease. 

Hughes: And yet, the popular image of the disease remained that of a gay 
disease. I question whether some of the physicians and 
researchers were not also trapped by that conception. 

Dritz: Well, we had thousands of gay men sick with it. There were only a 
handful of the hemophiliacs. 



Press Coverage 



Dritz: The press wasn't terribly excited about AIDS until Rock Hudson 
developed the disease. In the meantime, here in San Francisco, 
the Chronicle was publishing on AIDS. Randy Shilts had 
difficulties getting his editors to publish his stories, 
especially if there was a big murder on the front page. 

Hughes: What was the argument? 

Dritz: People aren't interested in the gays. Now, Art Ammann's baby who 
developed AIDS from blood trans fusion --that was news. In other 
words, something that will catch the reader's eye, because the 
newspapers have to build up their readership in order to sell 
advertising, which pays the bills. And that's business. I can't 
argue with it. But the press should be considered as a public 
agency, too, and therefore, they should feel some sense of 
responsibility for doing something just for the benefit of their 
readers. If there's something that the reader should know, even 
if it isn't very popular or profitable, they should print it. 

The newspapers might have been thinking--! don't know, of 
course- -that if they got too pro-gay, maybe readers would switch 
to the San Francisco Examiner. 



1 S . M. Friedman, Y. M. Felman, et al. Follow-up on Kaposi's sarcoma 
and Pneumocystis pneumonia. Morbidity and Mortality Weekly Report 1981, 
30:33, 305-307. (August 28, 1981) 



27 



Hughes: Do you think the perception of the disease as a gay disease, by at 
least some segments of the population, was a factor In the federal 
response, particularly In terms of dollars, to the AIDS epidemic? 

Dritz: Oh, yes. Because we had a very, very ultraconservatlve 

administration, both In Washington and Sacramento. If you think 
of President Bush and Vice President Quayle talking about decent 
morality now, It was even more so before, because they were 
worried about the fundamentalist groups. Right now, there aren't 
so many fundamentalist ministers on the air raking in thirty, 
forty, fifty million dollars anymore, because they have lost much 
of their following. 



Dritz: The press was very, very cautious. If you angered somebody in the 
top administration, it was quite possible that you wouldn't get 
the hint that if you were around the department offices at ten 
o'clock on Sunday morning, there was going to be something 
interesting happening, and maybe if you were a good boy, you'd get 
the first crack at It and beat out the other reporters. Those 
things happen. So the press had to be a little bit cautious 
during those years when the fundamentalist religion was riding 
high. Some homophobia must have played a role, too. 



Funding Problems 



Hughes: Well, another aspect of the slow federal funding, and there are 
many aspects, was that the epidemic coincided with a cutback at 
the federal level in practically all areas of health care and 
scientific research, the philosophy of the Reagan administration 
being to shuffle as much of the responsibility- - 

Dritz: To the states, and the states shifted it to the counties and 
cities. 

Hughes: Yes. 

Dritz: They were using all of their budget for Pentagon purposes, and 

they felt justified at that time. Much of the population agreed 
with them. They were worried about the "Evil Empire." I was 
worried, too, every time a jet went overhead, whether they were 
going to drop something on my children. But at the same time, I 
was a doctor; I had a responsibility to our population here 
through the health department. I felt that the responsibility 
included caring for these people, not just telling them what they 



28 



were getting, and telling them to cut unsafe sex out so they 

wouldn't catch AIDS. 

Now, the federal government's budget was geared to military, 
foreign affairs--! suppose they did something about roads, because 
they might have to run tanks across them. I'm a cynic. But they 
felt that health care should be the responsibility of the states. 
Now, the states passed the buck to the counties and the cities. 
The counties and the cities didn't have any money. The states 
said, "You are responsible for health care," but they didn't give 
them any money to do anything. 

So things went downhill. There wasn't any money. For 
example, it took more than a year to find the money to hire a 
statistician who could analyze the twenty-four-some pages of 
questionnaire that we used on 100 of our patients, to see if we 
could find out what was different about these people as compared 
to healthy gay people. We didn't know most of the healthy gays 
were infected with HIV then, too. 

Hughes: Was it not also true that the CDC was particularly affected by 
these budget cuts? 

Dritz: Well, health money was given to the National Institutes of Health, 
which has the Public Health Service, under which is the CDC. It 
has the NIAID- -National Institute of Allergy and Infectious 
Diseases. It has the National Cancer Institute, NCI. It has the 
National Heart, Blood, and Lung Institute, and a whole bunch of 
others. Now, they were given one bunch of money, one pie, and 
everybody had to compete. 

CDC asked for more money for this AIDS outbreak, but there 
wasn't going to be any more just for CDC. It had to come from 
somewhere else. The cancer institute wasn't going to give it up. 
NIAID wasn't going to give it up. Heart, Blood, and Lung 
Institute was doing a lot of research for open-heart surgery. So 
it was a scramble, and CDC was the orphan. We didn't get it. 

CDC's job was supposed to be, if there's a case of malaria in 
Louisiana, you go out there and clean it up. That's why they're 
down in Atlanta in the first place, because that was the place 
where malaria and the other deep South diseases were focused. CDC 
wanted to move to the Washington area, but they weren't permitted 
to. 

If there was an outbreak of a disease, CDC would go out with 
their regular questionnaires. They ask a zillion questions; they 
find out what's different about it; they clean up the pools of 



29 



water where the mosquitoes are growing that produce the malarial 
organisms, and they stop the outbreak, and that's it. 

Now, AIDS was a different story entirely. It wasn't a couple 
of cases or an outbreak of legionellosis- -which got millions of 
dollars spent for it, because these were straight men, war 
veterans. Great. I'm glad they helped them. But there would be 
millions of people involved here, and AIDS is a disease that was 
killing them 100 percent. Sooner or later, it was 100 percent. 
It still is. At least it's later rather than sooner now, but 
that's about all you can say for it so far. The average time of 
survival from diagnosis to death was ten to twelve months a few 
years ago. Now it is about eighteen months. 

So the CDC needed an awful lot of money, and couldn't get it. 
They were stretched so thin. There was Harold Jaffe running 
around all over the country. Jim Curran was running around 
talking. Don Francis was screaming. Bill Darrow was doing 
questionnaires. Dave Auerbach was circling the country. I think 
that's about all; five of them that I can think of [at the CDC). 
Oh, and Mary Guinan. She was taking testimony everywhere and the 
CDC investigators were bringing it all in. Then it lay there 
waiting for the computer, because there wasn't any money for a 
statistician. 

And the same way here in the city. Jay Levy is a top-notch 
virologist at UCSF. It's a state university, so the city couldn't 
offer any money. The state didn't have any money for him. He was 
trying to do tests to find out what was going on here, there, and 
everywhere, and he didn't have money for the equipment to do the 
testing, and couldn't get it. The money wasn't available, because 
it had to come down from the top. That was the point at which 
finally the gay community began to try to raise money. They 
twisted arms and they had cake sales and things, and raised a 
little bit. 



More on the Kaposi's Sarcoma Clinic 



Dritz: Marc Conant was able to get a $50,000 grant, which he used to hire 
Helen Schietinger as the nurse coordinator for the KS clinic. She 
made appointments, she ran around like crazy, and she did a 
marvelous job. Really killed herself for what salary she was 
getting. 

Hughes: That $50,000 came from the American Cancer Society, I believe. 



30 



[tape interruption] 

Dritz: After Marc had hired Helen Schietinger, we were able to do a 

little bit more with the KS clinic. Originally, it was chiefly 
dermatology weekly rounds. Since the first cases we had were KS, 
which is a dermatology problem, a skin cancer if you wish- -it's 
not really a cancer; it's something different--Conant would bring 
in his KS cases for us to see. The usual clinic- -all the doctors 
gather. 

In that clinic, after a few weeks of these sessions on KS , we 
began to see that the patients also had Pneuntocystis pneumonia, or 
we saw the scars on the forehead of a severe herpes zoster, and it 
became more than just a dermatology case, but they were coming 
through the derm clinic. Marc Conant at the same time was in 
private practice in dermatology. I believe some of these gay 
patients came to him as private patients after seeing him at the 
university, if they requested they didn't want to be a clinic 
case, they wanted a private doctor. 

So the KS clinic gradually began to show us different kinds 
of cases, and it became finally the KSOI clinic- -Kaposi's sarcoma 
and opportunistic infections. Then as some of the patients came 
in and had to be hospitalized, it became a hospital clinic, too. 

Finally, those of us who were there- -Dave Altman in 
gastroenterology, John Conte the UCSF infectious disease chief, 
Paul Volberding and Don Abrams as hematology- oncology, of course 
Conant, John Ziegler came from the Veteran's Administration 
Hospital, Francine Lozada from dental clinic, Jay Levy from 
virology, and once in a while one of the newspaper reporters would 
come in. Dave Perlman was very interested in AIDS and wrote very 
good, impartial articles. No patients' names, of course. Once in 
a while, we would meet with Charles Petit also. He usually does 
the physical sciences and is science editor for the San Francisco 
Chronicle, while Dave Perlman does the biological sciences. 

We began to have good free-for-alls there: "What do you 
think is causing this and what do you think is causing that?" 
Leon McKusick would come in; he is a psychologist. Paul Dague was 
there before that; he was the psychologist, a Ph.D. 
Unfortunately, he died of AIDS in that first year [January 1984], 
so he didn't get to do too much. We realized that our interests 
were much wider than just dermatology and hematology/oncology. 



31 



Support from Community Groups 



Dritz: The Kaposi's Sarcoma Research and Education Foundation went 

through some changes, and became the San Francisco AIDS Foundation 
in time. By that time, though, we were having input and 
cooperation and some funding from various AIDS organizations; one 
was the Shanti group. Jim Geary, the leader of the Shanti grief 
counseling group, was one of the people in that clinic. He's left 
Shanti since. Over a period of time- -I'm not really clear on a 
single step here and there- -the KS Foundation evolved into the 
AIDS Foundation, and then they became a fundraising group as well 
as a community service group. They were able to help Helen 
Schietinger put together some houses for those AIDS patients who 
had been thrown out of their homes, had no money, no place to go. 
They were on the street, and they weren't sick enough or eligible 
for hospitalization. 

With city and AIDS Foundation funds, we rented or bought 
three Victorians, four bedrooms each, and we were able to house 
twelve of the sickest patients there, and arrange with VNA, 
Visiting Nurse Association, and other home health aides to come in 
and bathe patients. The Shanti group had lots of volunteers 
gradually trained to buy groceries, bring food in, support the 
patients. 

Hughes: Was there any problem in the neighborhood where the Victorians 
were? 

Dritz: I don't recall that there was that much, because the houses were 

in the gay area. It worked out very well, except the first man to 
die of a group of four just shattered all the others. So the 
program had mixed effects, but at least it took care of the men 
physically, and a little bit emotionally, because the Shanti group 
sent in volunteers to sit and talk with them, hold their hands. 
They had grief therapy. 

Shanti had started simply as a grief management group, for 
persons who had friends who were dying of cancer, for instance. 
And when AIDS became the big problem in the city, Shanti became an 
AIDS support group. They did a wonderful job. 

Hughes: Had it always had an association with the gay community? 

Dritz: Not necessarily, but there were a lot of gay men involved in the 
Shanti organization. I'm generalizing, of course- -a lot of gay 
men gravitated to the health professions. They were nurses, they 
were aides, they were hospital orderlies, but there were real 
estate agents and businessmen and lawyers and doctors and 



32 



engineers among them too. A large percentage of the male nursing 
personnel was gay men. Aside from Ken Home who was Jim 
Groundwater's patient, the first AIDS patient we had with KS was 
Bobbi Campbell, who was a nurse. 

When Rock Hudson was finally recognized as a case of AIDS and 
died of it, Elizabeth Taylor funded with many millions- -the 
beginning of AmFAR, the American Foundation for AIDS Research. 
Rock Hudson had been a friend and a colleague. 

So there are now the two organizations. There's AmFAR, of 
which our former health director, Merv Silverman, is now the 
president, and there is the AIDS Foundation here locally in the 
city. AmFAR is a national organization. 

Hughes: Is there competition between the two? 

Dritz: I don't think so. The San Francisco AIDS Foundation raises most 
of its money here, and it does a wonderful job. It not only has 
housing for sick gay men, it has a food bank, and gay men who are 
mobile can come up once a week or every day and get food. They 
also have a sort of meals on wheels organization, which they 
developed. They deliver food to those who are home-bound. 
Otherwise, they would just die there. 

Hughes: San Francisco is known for its extensive community-based system. 
It seems to be a network that is unique to San Francisco. 

Dritz: That's right. It's unique in two ways. San Francisco has I think 
a higher per capita population of gay men than any other city- -not 
in actual numbers, but per capita. Also, San Francisco is unique 
in that it's so compact. It's only fifty square miles in area; 
it's a square seven miles on a side. 



The Health Department's 



Ltv Ties 



Dritz: We know all our medical community people, and all the doctors know 
each other, the patients practically know each other- -not only 
gay, but all the others. If something came up in the office, I'd 
just pick up a phone and say, "Tom, what's happening out there?" 
Or Tom would call in and say, "I've got this case here. Could you 
help me get a lab test on it?" 

So the health department worked closely with our medical 
community. We knew the gay organizations- -we knew the ones that 
hated us; we knew the ones that would work with us. We finally 



33 



realized that over these years of working first with the enteric 
diseases and now with AIDS, that gay men did trust our office, and 
they would cooperate. They came in and gave me confidential 
information, knowing that I wouldn't pass it on. 

Knowing what the needs were, we in the health department were 
able to work out an education program for the health community, 
for the doctors, and the lay people working in health. We were 
able to work out an education program for the lay community, both 
gay and heterosexual. We were able to work out a program for 
health services, ancillary health services, if you wish. And we 
were able to work with the press and television, all of that. We 
worked with CDC, California Medical Association, the American 
Medical Association, the San Francisco Medical Society- -their 
president, Glenn Molyneaux, was very supportive of us all through 
that period. I can't now remember all of the organizations we 
worked with. 

Each time we found a new need, we tried to respond to it. 
Much of the time we didn't have the money for it, but we worked 
out something, and the community cooperated. The gay doctors 
would cooperate. They came .in to clinics at private evening 
sessions to talk about cases, to talk about problems. 

As we were able to work out our responses to as many of the 
problems as we could identify, other cities began to pick up some 
of our methods, for instance, housing for gay men who needed 
homes, certainly the food bank and the meals on wheels. 

The gay parade in San Francisco is a good fundraiser. It's a 
raiser of sensibility for the population. Of course, it incenses 
a lot of people, too, but in general I think in San Francisco, we 
have become, if not accepting, certainly more tolerant of the gay 
lifestyle than we used to be. It shouldn't be necessary to be 
tolerant, even. People are people. My attitude was, what people 
do in bed is their own business- -unless it transmits disease, 
which is what I'm getting paid to prevent. So in that case, it's 
a different story. Besides, I'm a doctor; I should prevent it. 

Hughes: How did you weigh the pluses and minuses of the health hazard 
versus the civil liberties issues? 

Dritz: We were always behind the eight ball. We were always chasing 

after a good answer, a good way to do it. But if we found that 
the actions of infected patients were hazardous to their [sexual] 
contacts, and we had told them what not to do and showed them why 
they shouldn't and they were still doing it, then I tried to crack 
down. You couldn't put them in jail, because you couldn't prove 
what they had transmitted. And you don't do that. But we got at 



34 



them any way that we could. We could threaten then, "We'll tell 
your friends that you're infected." We didn't do it. But once in 
a while, we had to use a little body punch just to keep them from 
killing somebody else. 



Gaetan Dugas and the Cluster Studv 



Hughes: Well, maybe this is the time to introduce Gaetan Dugas, patient 
zero? 

Dritz: Well, he wasn't really patient zero. He was the first one from 
whom we could more or less prove that it was a transmissible 
disease. Bill Darrow and Dave Auerbach from CDC were doing 
interviews in California on patients with AIDS. This was when we 
were still doing our large questionnaire and trying to find out, 
is AIDS a transmissible disease, or is it some chemical in the 
environment? 

In their interviews, the CDC asked patients, "Well, whom did 
you have sexual contact with?" And have them name them. This was 
before confidentiality became a red flag, and justifiably, 
perhaps. You have to be politically correct here. 

Hughes: Which comes hard, doesn't it? 

Dritz: No, not really, but I have to be conscious of it. 

So they kept asking about contacts from patients they were 
interviewing. Several in southern California mentioned that one 
of their contacts, among many, was this handsome Canadian air 
steward. They didn't get the name. After maybe thirty or forty 
interviews, they kept hearing something about a Canadian air 
steward. And then finally, one man they were interviewing pulled 
out his appointment book. He said, "Yes, there was this Canadian 
air steward, and he was here just on Thanksgiving- -oh, wait a 
minute, I think I have his name in my book." And he pulled out 
the name. "Gaetan Dugas, that's his name." 

Now, Dave Auerbach and Bill Darrow had heard the name Gaetan 
Dugas a long time ago from Linda Laubenstein in New York. She was 
a cancer specialist there and Dugas saw her for a small purple KS 
lesion then. Doctors will mention patients' names to each other 
when they won't use the names in public. It was an unusual name, 
and they both remembered it. Dave and Bill went back and found 
that the other two who had mentioned the Canadian steward said, 
"Oh, yes, that's probably his name." After that, by talking to 



35 



people who had slept with Gaetan Dugas, or who had slept with 
somebody who had slept with Gaetan Dugas, they were able to put 
together what they called their cluster study. I think Gaetan had 
direct sexual contact with about forty out of two hundred and 
something, and the others had had contact second and third degree 
contact- -with him. 

So he was the first one for whom they were able to say, 
"Well, this man we know had AIDS. And these people slept with 
him" --or whatever they did with him- -"and they also have AIDS." 
They were able to put together a connection. This looked now 
very, very suspiciously like something being transmitted from 
Gaetan Dugas to others. 

Hughes: When did this happen? 
Dritz: It would have been in '82. 1 
Hughes: Before Art Ammann's baby? 

Dritz: Yes, that was before, because Art Ammann's baby then was the next 
nail in the coffin. (I shouldn't talk that way!) 

Hughes: Please finish with Dugas, because you had some more dealings with 
him before he died. 

Dritz: Bill Darrow and Dave Auerbach came back up to my office from 

southern California to talk to me, because I had a whole list of 
contacts listed on my blackboard there. You've seen pictures of 
that. Bill came in and he said, "Well, I've got a name now and a 
contact. Do you know any of these?" And he gave me Gaetan Dugas' 
name, and I had that name already. I showed him Gaetan Dugas had 
contact with Michael Maletta, a hairdresser from New York, and 
there was Dan Turk, who had a clothing store on Polk Street, and 
one or two other names. I would have to look back at the slides 
now to be sure. We're talking about almost ten years ago now. 
And they're dead now. 

I knew that Gaetan Dugas was still in town. I couldn't get 
to him, but I put word out, "If you see Gaetan Dugas, let him know 
I want to see him." He came up. I told him, "Look, we've got 
proof now." I didn't tell him how scientifically accurate the 
information was. It wasn't inaccurate, but it wasn't actually 



1 S. Fannin, M. D. Gottlieb, J. P. Wiessman et al. A cluster study of 
Kaposi's sarcoma and PneumocysCis carinii pneumonia among homosexual male 
residents of Los Angeles and Orange County. Morbidity and Mortality Weekly 
Report 1982, 31, 23:305-307. (June 18, 1982) 



36 



Hughes : 



Dritz: 



scientifically proven. I said, "We've got proof that you've been 
infecting these other people. You've got AIDS, you know. We know 
it's transmissible now, because you're transmitting it." He was 
the active partner in all this gay business, anal-genital sex. 
"You've just got to cut it out." 

"Don't be silly, I won't cut it out. It's my life. I'll do 
what I want." I said, "Yes, but you're infecting other people." 
"I got it. Let them get it." I said, "You've got to cut it out!" 
"Screw you." He walked out. I never saw him again. It was a 
pity, because he was apparently an intelligent man, except on this 
one point. And he was very, very sexually active. He was a 
presumptive proof that AIDS was something transmissible from an 
infected person directly to the uninfected person. 

You mentioned your diagrams of transmission. Was he the first 
that reinforced the idea of a transmissible agent? 

I had a lot [of indication] that it looked like AIDS could be 
transmissible. There was all this contact among these men, and 
they all had the disease, one kind or another. On the other hand, 
all of these men were having other contacts, too, and we didn't 
know then that the incubation period was a long number of years in 
some cases . 



Hughes: Right. And they were maybe using the same poppers or-- 

Dritz: Whatever, yes. And we didn't have the answer on the poppers yet, 
because CDC was still waiting for money for a statistician to run 
the computer analysis on the questionnaire. So the problem then 
was to test the rest of our theories about transmission, and that 
didn't happen until the end of '82. 



Transfusion AIDS at UCSF 



Hughes: With Art Ammann's baby. 

Dritz: Let's go on to Art Ammann's baby, because that was where we knew 
we had an infectious disease. Well, we had the hemophiliacs, 
too- -we knew something was being transmitted into the bloodstream. 

#* 

Hughes: You have spoken of Art Ammann's baby as the nail that sealed the 
coffin. Tell me why it was so conclusive. 



37 



Dritz: Well, we had Gaetan Dugas, presumptive evidence. We had 

hemophiliacs, presumptive evidence, although they were not in 
direct contact with gay men. They were not in direct sexual 
contact with anybody, except their own wives. They were not 
getting blood transfusions, but they were using Factor VIII and 
Factor IX, which are made from pooled human plasma, collected in 
plasmapheresis centers. The collecting organization pays men to 
donate their blood, the plasma is removed, the red cells are shot 
back into their veins, and they go off, for pay. Now, the people 
who will come into a plasmapheresis center- -which were all in the 
drug-sex Tenderloin area or south of Market [in San Francisco] -- 
will be those who are probably a high-risk population anyhow, if 
they sell their blood for money. 

So we had plasma being concentrated down from maybe 20,000 
donations into Factor VIII and Factor IX, and segments of the 
plasma being injected into hemophiliacs to prevent excessive 
bleeding, which is the characteristic of their disease, following 
trauma of some kind. 

Factor VIII and Factor IX had not been used too many years 
before that. I don't remember exactly when. But just at about 
the time that the AIDS cases were beginning to appear here, New 
York was reporting one or two cases of hemophiliacs with AIDS. 
They were heterosexual; they had nothing to do with the gay 
community; they didn't even live in that gay area. They had no 
contact with this area. And yet they were getting AIDS. Now, 
why? The only thing that we, the scientific community, could see 
that was common with the hemophiliacs and the gay people who were 
apparently getting injected with the virus was that they must be 
getting it from plasma. So that was a presumptive, a very 
terrifying presumptive, suggestion that it was a virus in the 
bloodstream of infected persons. 

Now, Art Ammann had the idea, and he has to get full credit 
for it. He wrote the paper; he's the prime author on it. 1 He 
said, "I've checked this baby back and forth for combined immune 
deficiency," which is the congenital form. The plastic -bubble 
baby was one of those. Well, "This one," he said, "isn't 
characteristic. The blood counts aren't characteristic. The cell 
counts aren't characteristic. And yet this kid is getting 
diseases one after the other. His immune system is down. Maybe 
it's like AIDS. He did have blood transfusions." 



: A. J. Ammann, M. J. Cowan, D. W. Wara, H. Goldman, H. Perkins, S. 
Dritz. Possible transfusion associated acquired immunodeficiency disease 
(AIDS). Morbidity and Mortality Weekly Report 1982, 31:652-653. (December 
10, 1982) 



38 



The baby had an Rh factor condition in which the baby's blood 
is destroyed by antibodies from the mother's blood. That doesn't 
happen any more, because as soon as the mother's first baby is 
born, she can be immunized against the Rh factor, so she doesn't 
destroy the blood in the second baby. 

The affected baby's blood simply has to be completely 
exchanged, which meant that in the course of the first week of 
Ammann's baby's life, its blood was exchanged with blood fractions 
from thirteen donors. Because Ammann thought it was AIDS and I 
was working the AIDS problem in the department, he called me. So 
I called the Irwin Memorial Blood Bank. Of course, they 
cooperated. We had worked a lot together on hepatitis B and 
hepatitis C, transfusion-mediated hepatitis, so we had rapport 
there . 

We got the thirteen donors' names, and right in the middle of 
them was number seven, an AIDS patient in San Francisco, already 
dead. I can still see it on that yellow page that Herb Perkins 
sent me. I won't use the patient's name that I recognized from my 
AIDS case file. And the same birthdate; there wasn't any question 
that the donor was our AIDS patient. 

So I called Art Ammann and I told him that the blood donor 
was an HIV case. This was November of '82. The man had already 
died, vehemently denying that he was gay. That was not true. We 
proved it later from his medical records. The interesting thing 
was that the date of onset of his symptoms was seven months after 
he had made the donation. He hadn't known he was sick then, and 
of course, the blood couldn't be tested for we didn't have a test 
for AIDS. It had been tested for hepatitis, and he didn't have 
that. 

I called Herb Perkins at the blood bank. He was medical 
director of the Irwin Memorial Blood Bank. I told him what we 
had. He must have had a heart attack. 

Hughes: What did he say? 

Dritz: I don't remember what he said, but it might be something like, 
"Oh, my." He is a perfect gentleman, and wouldn't cuss. 

Hughes: Because the significance must have hit both of you: AIDS was 
transmitted by blood. 

Dritz: Oh, yes. Well, it hit Art Ammann too, because at UCSF they were 
transfusing a lot of babies with Rh factor problems. And 
transfused adults also had to be considered at risk. 



39 



Hughes: Right. And you already knew about cases of AIDS in hemophiliacs. 

Dritz: That's right. So then I called CDC and told them this new 

development, and Harold Jaffe talked to me on the phone. He said, 
"Oh, Gads! We've been afraid of it." Because with the 
hemophiliacs getting it, we'd already been afraid. This was the 
end of November of '82, into December. 



The Centers for Disease Control Blood Transfusions 
Workshop/Advisory Committee Meeting. January 4. 1983 



Dritz: On January 4, 1983, the CDC convened a national meeting with all 

the health department people and the blood bank people. We met in 
Atlanta. CDC called me and they said, "Come in, we've got to have 
you here." After all, our office "discovered" the case [of the 
baby with transfusion AIDS], if you wish. I told him I'd be glad 
to fly to Atlanta, but I couldn't afford the money. The round 
trip was over $800 at that time, plus taxis and the hotel. Health 
department people don't get that much money. It's not like a 
neurosurgeon or a plastic surgeon. 

Hughes: Decidedly not. 

Dritz: So they said, "We haven't got the money, either." I asked the 
city- -"No way." I called back and asked CDC, could they get it 
from the feds somehow? They couldn't get it. Finally, one of 
their finance officers called back. He said, "We've figured out a 
way. We can't pay for you to come here as an employee of the city 
health department. If you're an employee of the city health 
department, they have to pay for you. But we could categorize you 
as a medical consultant, an independent contractor, and for that 
we can pay for you to come." And that's how we worked it out. 

This is what funding was in those days . And they gave me 
$1,100 I think to pay for the round trip, one meal, and one night 
in the hotel. I couldn't fly the red-eye in and spend the whole 
day at the meeting and then fly the red-eye back again. So they 
paid for one night in a hotel. 

The money was a big problem at every stage. I was asked to 
come up to Eureka and Arcada in northern California to lecture. 
The fire department, police department, the EMT- -emergency medical 
technicians --the ambulance people there were worried, "Will we 
catch AIDS by doing mouth -to -mouth resuscitation?" So I went up 
there to talk with them, and I brought them the prototype that our 



Hughes : 



Dritz: 



Hughes: 
Dritz: 



Hughes: 
Dritz: 



fire department had worked out, a barrier so that they could give 
mouth -to -mouth without actually touching the skin of the patient. 

I did that on my own money. I was able to use a city car to 
ride up there and back- -six-hour drive each way- -but I had to pay 
for my own gas. That's the way the city was. Well, you did those 
things. I wasn't flush, but you're a doctor. It was that way. 



Well, go back to the Atlanta meeting, 
was like. 



Tell me what the atmosphere 



It's hard to say that it was an atmosphere. If you think of a 
beehive with all the bees buzzing back and forth, it was that kind 
of feeling. People were tense. There was nothing calm or quiet 
about it. It wasn't a bunch of scientists sitting in their tweed 
jackets with a pipe in their mouth, talking. These were people 
who might have their careers or their organizations or their 
businesses at risk- -great risk. 

Was the press there? 

The press was there, too. There must have been thirty of us at 
least, maybe more, sitting around a hollow square table, and along 
the walls were the press, lots of people there. For a while, I 
wondered, who were all of these observers? Then somebody 
mentioned it's the press. Herb Perkins was there with me. I 
recognized one or two of the men from the plasmapheresis centers. 
The New York Health Commissioner, David Sencer, was there, James 
Goedert was there, Aaron Kellner of the New York Blood Center, 
other New York people- -hard to remember all of them. The 
Pharmaceutical Manufacturers' Association, the FDA [Food and Drug 
Administration], American Association of Blood Banks, the American 
Red Cross, the Hemophilia Foundation, and more. 

Who is Goedert? 

A physician at the National Cancer Institute who worked on AIDS. 
They played musical chairs from one NIH institute to another. I 
don't recall his exact title at that time. This took place ten 
years ago, now. 

To begin with, it was just like any CDC convocation, if you 
please. CDC staff presented the materials first that we were 
going to be discussing, and their views of what the problems were. 
And then it was opened for discussion. 



Hughes: Did Art Ammann's baby figure in their presentation? 



41 



Dritz: Well, we had proof here that the baby had been transfused with 
blood from a person who later had been diagnosed with AIDS and 
subsequently died. We still couldn't prove that that particular 
blood gave that baby AIDS, but it was as presumptive as it could 
be. The only way you could prove transfusion transmission would 
be if you took somebody known with AIDS and somebody known without 
AIDS and you injected the AIDS blood into the test subject, and 
later he came down with AIDS, and there were no other sources for 
him to get it. 

Hughes: It would be an impossible experiment. 

Dritz: That's right. Now, there was always the possibility- -we didn't 
know it then yet- -but when a person is infected with AIDS, there 
is a latent period- -a couple of weeks to a month or two, maybe 
three- -before the blood develops the antibodies to a degree where 
you can count them and recognize them. Now, during this period, a 
person could be infectious with AIDS and we wouldn't know it. 

We didn't know whether the other twelve donors at that time 
maybe were incubating AIDS too. We checked back; none of them 
came down with AIDS. So again, it was pretty certain that this 
baby had not been infected by anyone else but the blood donor 
[with HIV]. The baby was in an incubator in a hospital it could 
hardly get infected any other way. A hospital needle supposedly 
could be contaminated, but there were no AIDS cases known in the 
hospital at that time, certainly not in the nursery. And 
everything used there is sterilized. It wasn't due to multiple 
uses of a single needle. So it had to be from the infected donor. 
Where was I? 

Hughes: You were talking about the CDC presentation. 

Dritz: Oh, yes. So first, Jim Curran, the director of the AIDS unit at 
CDC, presented a number of cases- -I'm a little vague on the exact 
details now. 

Hughes: That had been transmitted through blood? 

Dritz: No. This baby was the only case we knew that was transmitted 
through blood. The hemophiliacs maybe were getting it through 
pooled plasma. But he was presenting that, "We seem to have a 
problem with the blood supply now. There is this case that's been 
transfused, and there are hemophiliacs that have come down with 
AIDS for whom presumptively the only source was contaminated 
plasma, because it comes from a relatively high-risk population." 

Then it went on to Harold Jaffe with some of the 
epidemiology. It went on to Tom Spira, the head of CDC's virology 



department, who gave a run-down on the various tests we have 
available now for eliminating possible sources of infection of any 
kind in the blood. We have hepatitis B core antibody tests that 
was new then. We had already hepatitis B surface antigen tests. 
We didn't have a hepatitis A test yet. We could test for malaria, 
rickettsia, legionellosis, tuberculosis, and others. But we 
couldn't test for an AIDS antibody or an AIDS virus, yet. We can 
now. 

Spira had put together tabulations of the incidence of these 
positives in different populations, showing that in a gay you 
could expect higher levels of hepatitis B core antibody or 
hepatitis surface antigen. He said, "We don't have a test for 
whatever this infectious agent is." We weren't calling it AIDS 
then yet, I don't think. 1 No, we didn't call it HIV [human 
immunodeficiency virus] yet, because that wasn't until after 
Robert Gallo and Luc Montagnier had their two different names for 
the virus, which were changed later to HIV. 

So he said, "We still don't have proof that AIDS is a virus. 
But it must be something like that, because it isn't anything else 
we have. We don't have any test for it, but if you use tests 1, 
2, and 3 on every blood unit, maybe we'll have better presumptive 
evidence that this might be high-risk blood." However, his 
tabulations listed, among other things, hepatitis B core and 
surface antibody levels in gay AIDS patients, versus "healthy 
gays." We learned much later that many of the "healthy gays" were 
already infected. 

The blood banks were already asking patients, "Have you ever 
been in the malaria areas? Were you in Vietnam? Were you in 
India? Have you ever had hepatitis? Have you ever had jaundice? 
Did you do a lot of drinking? Is your liver off?" And with all 
of that questioning, they tried to eliminate high-risk people 
without asking, "Are you gay?" Because that was the one thing we 
couldn't do- -the confidentiality and civil rights issues. 

The gay community and the liberal community were very, very 
adamant that you couldn' t-- what's the word?--"out" a gay person. 
And they had some justification for their fears, because they were 
losing their social contacts of every kind--their work, insurance, 
lovers, everything. On the other hand, the conservative 
population had justification for their fears, too, that if we 



1 Some point to July 27, 1982 as the date when the CDC adopted AIDS as 
the official name of the new disease. (Bruce Nussbaum. Good Intentions: 
How Big Business and the Medical Establishment are Corrupting the Fight 
Against AIDS, p. 86.) 



43 



didn't identify these people, other people were going to die 
because this diagnosis of AIDS meant eventual death. 

[tape interruption] 

Dritz: So after Tom Spira finished his list of proposed surrogate tests, 
because we didn't have an actual test for HIV, then Don Francis 
got into the discussion. He said, "We've got to do something to 
prevent the use of contaminated blood. This disease is 
infectious." Now, he had been very, very essential in wiping out 
smallpox in Africa. He had led the World Health Organization 
fight against smallpox. If anybody killed smallpox, it was he. 
He's a fantastic, devoted health person. He said, "We've got to 
do something about cleaning up the blood supply and preventing the 
use of any more contaminated blood." 

Then it was open for discussion. Some of the blood bankers I 
suppose were being responsible to the medical needs of the 
community. They didn't want to lose their blood supply, and they 
didn't want to have to do all this battery of surrogate tests, 
because the results wouldn't be definitive. They'd have to raise 
the price of blood transfusion, and that would make it more 
difficult for people to pay it. They'd have to get more 
technicians in, and it would cost them a lot more money. 

They made the point repeatedly- -they didn't convince us --that 
Ammann's baby was only one case, and it could have been a freak, 
and after all, we have ten million transfusions a year in this 
country, and this is the first one with the possibility of HIV 
contamination. Of course, we didn't know until '85 how many more 
cases were already incubating. There are several hundred known 
now in 1992. 

Hughes: Were they factoring in the hemophiliac cases as well? 

Dritz: That wasn't proved. You couldn't say, "This injection caused this 
AIDS in this person." It was all presumptive. And yet, we had to 
say the only way the hemophiliacs could be getting AIDS was from 
Factor VIII and Factor IX, which comes from high-risk plasma 
pools. 

And the only way this baby could have got it was from its 
transfusion. But you couldn't prove it. They could have argued 
that maybe the donor didn't have AIDS when he gave blood to the 
baby, because he didn't get his symptoms until seven months later. 
Well, now we know there's a long incubation period. He was 
already infectious. His case proved AIDS can be infectious before 
symptoms develop. And we didn't have an HIV test then, so we 
couldn't prove it. Without the scientific proof --you inject it 



44 



here and it develops there, and then you take it from this one and 
you inject it in a third one and the third one gets it, then you 
prove it- -Koch's postulates. 

Hughes: One might argue that if something is significantly presumptive, 
why not err on the side of caution to protect the blood supply? 

Dritz: That's what we were saying in Atlanta. It went round and round; 
the blood bankers --not all of them- -were adamant. Some of them 
were just quiet. They didn't want to say, "Well, we ought to stop 
taking donations from high-risk persons." It might have been 
Francis- -somebody at the table said, "Well, why don't we just not 
take donations from any gay people?" It wasn't a blood banker. 
Because Perkins told me that 5,6,7 percent of his blood bank 
donations were from the gay community. They were very, very good 
about donating. They were very socially conscientious people. 

Hughes: To sum it up, the blood bank people were interested in preserving 
the volume of their donations? 

Dritz: Well, preserving the volume of the donations and preventing the 
escalation of their cost base with all this. 

And at the end, there was no consensus. I asked them, 
"Please, tell us what you want us to do. This is a national 
group, we're a medical consultant panel, what do you want to do? 
I have 700,000 people in my city. I have a population with a high 
percentage of gays. We have a bunch of big hospitals. We use a 
lot of transfusions. Our Irwin Memorial Blood Bank needs the 
blood." And Herb was sitting right next to me there. "What are 
we going to do?" And there was no consensus. 



Testing Blood for Viruses 



Hughes : 
Dritz: 



So you went away not having any policy to follow? 

There wasn't any policy. They finally decided, well, maybe it 
would be a good idea to do a hepatitis B core antibody test [on 
donated blood] , for which the equipment and the machinery was just 
beginning to come on the market. Maybe we should test gay blood 
against heterosexual blood for the hepatitis B core antibody. 
Spira had shown that he thought the antibody would be higher in 
the gay group than in the straight group. But when we checked it 
over, the difference was not statistically significant. 



45 



Hughes: If you did use the hepatitis B core antibody test, then that would 
mean discarding any positive blood. 

Dritz: Yes. Up to this ppint, they'd been doing hepatitis B surface 

antigen tests. Any positive, they dumped the blood right away. 

Hughes: I know the surface and core antibody tests are different, but 
aren't they testing for the same problem? 

Dritz: No, because the surface antibody may disappear. The core antibody 
doesn't. Now, if the surface antigen has disappeared, you test 
for that, and the blood seems all right. The core antibody is 
still there and can be infectious. And we didn't have a test for 
that until just about that time [early 1983]. The test for 
hepatitis C has just become available. Until recently, we 
couldn't test for it. And so we still had transfusion-mediated 
hepatitis being reported into the city. Although we tested for A 
and we tested for B, this was hepatitis C, formerly called non-A, 
non-B, for obvious reason. Now we can test for that, too, so 
there won't be any more transfusion-mediated hepatitis due to the 
C agent. There may be a D; we don't know yet. 

The New York and the San Francisco blood banks decided they 
would try to see whether there was a difference in the hepatitis B 
core antibody in gay versus heterosexual or in high-risk versus 
apparently low-risk populations. Of course, the apparently low- 
risk gay population were already heavily infected, too. Not every 
one, but the numbers were going up, and we didn' t- -couldn' t- -know 
it. 

In '78, there were already 4 percent infected. When we went 
back retroactively and tested the bloods of the hepatitis B 
vaccine trials, 4 percent of them were already HIV positive. We 
didn't even know there was such a thing as AIDS then. By '84, 60 
percent to 70 percent of a gay population was infected. Now, the 
general population of males in the city, by the time I retired 
[1984], was less than 1 percent infected. But among the gays, it 
was about 3 percent with AIDS. I retired in '84; the test wasn't 
licensed until March of '85. After they were tested, they found 
maybe 3 percent of them were sick with AIDS, or presumptively 
getting the symptoms, but over 60 percent of them were incubating 
it. 



46 



[Interview 3: July 6, 1992] ## 



The Medical Advisory Committee on AIDS. San Francisco Department 
of Public Health 



Purpose and Membership 

Hughes: Dr. Dritz, when and why was the Medical Advisory Committee on AIDS 
at the San Francisco Department of Public Health formed, and who 
composed it? 

Dritz: Well, it was formed because there was so much difficulty and 

confusion and splintering among all the parties who were involved 
in trying to get some answers to what was happening in the gay 
community. We already were quite certain that AIDS was an 
infectious condition, and therefore a transmissible disease. 
Therefore we had to find out how we could stop the transmission, 
which meant getting to the people at risk, getting to the people 
who could help those who were at risk. 

Since there were so many different agencies involved- -the 
city government, the health department as a fraction of that, San 
Francisco General Hospital as a treatment arm of the health 
department- -it was different than most other big cities. The 
university, the pharmaceutical people, the researchers, the 
medical society, organized medicine, the gay community- -there were 
so many factors entering into it, plus the press and the media, 
that we simply couldn't just go by fiat and say, "This is what the 
health department wants to do, and that's it." 

So Dr. Silverman, as director of the health department, felt 
that he'd better have an advisory committee composed of 
representatives of as many of these different factions as was 
possible. I use the word faction advisedly, because a lot of them 
were fighting. 

I represented the health department's Bureau of Communicable 
Disease Control for him, and I was unofficially his advisor on it. 
I was developing all the information that he later used. He was 
smart, though. He knew his business, too. There was Merle Sande. 
He was chief of medical services at San Francisco General 
Hospital, where the AIDS outpatient clinic was developing. I'm 
not sure if Ward 5B [the AIDS ward] had opened yet or not. 

Hughes: It opened in July '83. 



47 



Drltz: I think that we started to meet in late '82. 1 

Then there were Bob Bolan and Rick Andrews, both physicians 
with large gay practices, representing the gay community and the 
BAPHR--Bay Area Physicians for Human Rights- -which was the San 
Francisco branch of the American Physicians for Human Rights, a 
New York organization. And there was Dr. Glenn Molyneaux, 
representing the San Francisco Medical Society. I think he was 
the president at the time. Another member was Dana van Gorder, 
who was administrative aide to Supervisor Harry Britt, the one gay 
member of the San Francisco Board of Supervisors. He had replaced 
Harvey Milk, who had been assassinated at the same time that Mayor 
George Moscone was assassinated. 

At intervals, Marcus Conant from UC dermatology came in. He 
had organized and was running our KS clinic. Occasionally, Dave 
Perlman from the San Francisco Chronicle would sit in, but that 
was all off the record. 

Hughes: Did the committee insist that he keep information off the record? 

Dritz: No, he reassured us that it would be off the record unless we said 
he could use it. Actually, we could have asked him, "How do you 
think the press will present this?" We were not thinking in terms 
of the press, but rather in terms of what we could do to get word 
out effectively to the population at risk about the things we 
thought they should do or not do to protect themselves from 
transmitting what we were practically sure now was a transmissible 
disease. 



Giving Advice 



Dritz: We came up with various suggestions- -educating the community, 

working not to isolate but to give medical support to the people 
who were already sick and dying very fast, how to deal with a 
public who were afraid to ride a bus through the gay community, 
how to deal with the undertaking establishment which refused to 
prepare deceased AIDS patients for burial. They called in to say, 
"We're not going to do it. We can't embalm them because we could 



March, 1983, Mervyn Silverman established "an ad hoc medical 
advisory committee to my office" to "keep abreast of [AIDS] developments 
and present as consistent a response as possible to the public on matters 
relating to AIDS..." (Marcus A. Conant, KS Notebook, 1983) 



48 



stick ourselves." We couldn't tell them for sure that they 
wouldn't get infected. 

There were nurses' representatives, and other health workers, 
who were worried about getting needle sticks. We had to find some 
way to talk to them, to clarify what we thought we knew about this 
question. We had to make it clear that whatever we were saying 
might change as the epidemic went ahead. 

This was an advisory committee that eventually came up with 
general conclusions on the questions at the moment. Dr. Silverman 
accepted them or had his own reservations about some of those. He 
had major input, because he was a very, very experienced public 
health director. He had been with the U.S. Public Health Service. 
He had directed the Wichita, Kansas, health department. He knew 
his business very thoroughly, and so he would accept or change or 
take in toto what we had decided at any one of the biweekly 
meetings . 

Sometimes, he would be overruled by City Hall, because there 
was an awful lot of politics in this. The input from the BAPHR 
representatives, for instance, and from the board of supervisors, 
was almost always purely political. BAPHR was represented by 
physicians, and they were concerned for their patients, just as 
any physician would be. At the same time, they also expressed the 
unique view of segments of the gay community [about the need to 
preserve civil liberties] . We could understand when they voiced 
it, but we couldn't present it ourselves, because we didn't think 
in those terms until we learned to understand what they were 
saying. 

So it was medical, it was public health, it was preventive 
medicine, and it was a hell of lot of politics. The only term for 
it is a can of worms. No matter how you twisted it, some other 
factor came up. "Let's do this." "I think we can reach them in 
this way." "Yes, but--" And there was always a "yes, but--" No 
matter what you said, there were three objections for four 
different reasons from members of the committee. We tried to work 
cooperatively, and we did do a reasonable job. 

The one thing the advisory committee did do was give Dr. 
Silverman a stronger hand for his arguments to City Hall, because 
he wasn't just saying, "This is what 1 think as a doctor," but 
"Everybody else has input. This is what we all decided, and this 
is what we think should be done . " And the hand would come down in 
Room 200--that's City Hall--"Nj>." I'm not naming names. 

Hughes: Give me an idea of the types of issues that the committee would 
discuss . 



49 



The Bathhouses 



Dritz: Well, number one was the baths, because we knew that was the main 
source of AIDS transmission. A gay man could pick up one or two 
partners In a bar, and they'd go off someplace to have their fun. 
There were back rooms in the bars, in the baths, too. They were 
called orgy rooms, where ten, fifteen, twenty, thirty, forty men 
were dancing around with almost no light, and of course, anything 
happened there. That explained to us why a gay man would say, "I 
don't know who I got it from. I never saw his face." That sort 
of thing. 

The bars were not the best places to be, but at least, they 
would limit the amount of contact a man could have. In a 
bookshop, in a small sex club, out in the park- -these places 
limited the contact. But in the baths... At a four-story 
bathhouse, Club Baths south of Market I think it was, 350 men 
would gather on a Saturday night at $10 a crack, and they got 
their $10 worth. And more. Including drugs in addition to 
poppers. 

Would you permit a child with measles to go to school with a 
classroom of thirty other children? No! It's a transmissible 
disease. You exclude him, and if the whole room has been exposed, 
then you close that classroom- -you discontinue that class and send 
the kids home. There was quarantine for these diseases at one 
time. In Africa, if one or two patients came up with smallpox, 
you isolated the village, and you vaccinated everybody. So after 
the smallpox was finished with that patient or those two patients, 
it had no place else to go. 

We didn't have a vaccine for AIDS. We had the disease 
spreading wildly. We knew that the numbers were going up 
geometrically in those first two years. The numbers of new cases 
were doubling every six months. It was terrible. 

Hughes: But times had changed. Society was putting much more emphasis on 
individual rights, particularly for minorities such as the gay 
population. It was no longer as acceptable for a government 
agency to do what some factions regarded as removing individual 
rights. 

Dritz: That's right. It was not only civil rights and individual rights, 
but the federal government was also saying, "We have too much 
government now. Let's concentrate on the threat from the Evil 
Empire overseas." This epidemic was going to wipe us out, and 
they didn't even care about it. 



50 



Any physician who has any sympathy or sense of responsibility 
toward his patients, to the population, toward his own family, 
would say, "You don't waste money up in the sky on nuclear weapons 
against a theoretical threat, when you have the threat right here, 
right now, killing you, just as deadly as a bomb." Central Africa 
now we know is going to be wiped out by AIDS just as if they threw 
a couple of atom bombs in there . 

The emphasis was not so much on civil rights as on fear in 
the gay community that if they were "outed," made known that they 
were gay, that they would lose jobs, friends, a place to sleep, 
insurance. All of these things made them resist closing the 
baths, because their incognito activities in a closed environment 
in the baths kept them from being known on the outside. Now, 
there were gay men who were aggressively out, the S&M, 
sadomasochist, men, the leather boys we called them, who walked up 
and down Market Street dressed in leathers with leather caps like 
the old Nazi men, and chains, and leather boots. But they were 
the ones that died fastest, because generally speaking, they used 
the most traumatic anal-rectal techniques, and got infected. They 
had been infected with many other sexually transmitted diseases 
before then, so they were in no shape even to postpone the 
activation of the AIDS virus after it hit them. 

I can talk about the meeting we had when Dr. Silverman was 
about to announce that he was going to close the baths, then he 
didn't, because the mayor and he couldn't get together on it. I 
wasn't in on that session between the two of them, though, so I 
can't give you all the details. 

Many members from the gay community were at that meeting. 
Bobbi Campbell, who was already infected with AIDS, was standing 
at the back. I remember at least three members of the gay 
community, nude, just with towels around them, holding signs that 
said, "Today the baths; tomorrow the ovens." They meant that, if 
we let you close the baths on us, next thing you'll quarantine us, 
then we'll be in jail, then you'll destroy us, like a Hitler. It 
was very, very extreme. 

Now, through Rick Andrews and Bob Bolan, we could perhaps get 
through to some of the other members of the medical community 
dealing with AIDS patients, so that they could all put out the 
message in comparable terms to their different patients, "Don't do 
this risky sex practice." But of course, if the men were 
patients, they were already sick. 



Hughes: It was too late. 



51 



Dritz: We had to reach those that weren't infected yet. We didn't know 

that by '83, or even late '82, we already had about 10, 12 percent 
of the gay community infected. We didn't find that out until we 
ran the hepatitis B follow-up study later, with Winkelstein' s 
report. 1 

So we were working partly in the dark. We were shedding as 
much light as we could on the people we were trying to reach. 
Marc Conant was backing us on trying to close the baths , because 
he saw from his own patients at UCSF and what he heard from the 
gay community that too many things were going on that simply would 
spread the thing beyond anything that we'd ever seen. Well, the 
Black Death, the plague in the Middle Ages, wiped out one -third of 
European population over a period of a couple of years. This 
epidemic eventually is going to wipe out that much of the general 
as well as gay population unless we can get a vaccine for it and 
medical treatment. 



Fear of Infection 



Dritz: There was the treatment issue: how do you treat them? Merle 

Sande was screaming, "We need money for the San Francisco General 
Hospital. We've got a[n] [AIDS] clinic here. We've got Paul 
Volberding, we've got Don Abrams, we've got maybe a couple of 
interns. And the nurses, a lot of them are very devoted. And 
some of them just don't want to have anything to do with AIDS 
patients. We have a lot of aides who are justifiably afraid, 
because we can't assure them 100 percent that they won't catch 
anything, although we're pretty sure they won't." 

We knew it didn't go through the air, because AIDS patients 
who were sick at home did not produce cases of AIDS in their 
immediate intimate daily household contacts. We were pretty sure 
it was blood-transmitted, needle -transmitted, cut- transmitted, 
something like that. 

So Sande needed money for better infection controls, for 
better equipment at the hospital, for better management, for more 
dedicated nurses. They actually did manage to give nurses the 



HJ. Winkelstein, D. M. Lyman, N. S. Padian, R. Grant, M. Samuel, J. A. 
Wiley, R. E. Anderson, W. Lang, R. Riggs, J. A. Levy. Sexual practices and 
risk of infection by the human immunodeficiency virus: The San Francisco 
Men's Health Study. Journal of the American Medical Association 1987, 
257:321-326. 



52 



option to transfer to the AIDS clinic and the AIDS ward at San 
Francisco General Hospital, and some of them did that. It was 
marvelous. 

On the other hand, there were concerns -- the nurses' concern, 
physicians' concern for the health workers' safety, our inability 
to tell them how safe or unsafe a specific job might be, and the 
medical unions' objections too, and the fact that a nurse or an 
aide might get AIDS and die of AIDS and the family could sue the 
city for $100 million for not protecting them. All of that. 
There were financial considerations to that, too. 



San Francisco Medical Society 



Dritz: The medical society simply wanted to be cooperative, and it was. 
There were some reactionary physicians in the medical society, 
just as there are reactionary persons in any population. But the 
majority of them were only admirable. 

Hughes: How did they help? 

Dritz: Well, when we wanted word spread among the physicians of the 

medical society about the new things we were learning- -it took 
maybe six months for a paper to get published, to be readthey 
would transmit that information. Silverman or Sande could talk at 
a meeting of the medical society. I didn't talk there, because 
they were superior to me in the department. 

We needed advice from members of the medical society: "How 
do we get this information to doctors who are dealing with 
patients in the Fillmore [District]? What's the best way to talk 
to people about this without turning them off?" The Fillmore at 
that time was primarily black, strongly criminal, and a high drug- 
using area. You'd talk about AIDS to some of the doctors, and 
they'd say, "I don't want anything to do with it. I won't treat 
those patients." Just as some doctors will say, "I won't have 
anything to do with Medicare. I don't want anything to do with 
socialized medicine." There are reactionaries among us. 



San Francisco Board of Supervisors 



Dritz: We needed the input from the board of supervisors, because some of 
them could influence the other members of the board--! forget if 



53 



Hughes : 



Drltz: 



there were nine or eleven members at that time and that too could 
influence the action of the mayor. The mayor couldn't override 
the board of supervisors short of a two- thirds override on a veto, 
but she could say, "Next time you want something passed here, you 
must listen to what we think is the best way to do it for all the 
population, "- -politically correct words. 

Did Harry Britt transmit the information to the committee which 
you wanted transmitted? 

Not only transmitted, but he gave us a lot of input of the 
thinking of the gay community, too. 



Health Deoartment Relationships vith Other Agencies 



Local, State, and Federal Agencies 



Hughes: The next step is to talk about the agencies that were involved 
with the AIDS epidemic in San Francisco. I'm thinking of the 
slide that you showed me of the relationship between the San 
Francisco Department of Public Health and various institutions and 
groups. [see appendix] 

[tape interruption] 

Dritz: We had developed step by step, over the period of those first 

three years, our own complex program for handling the different 
aspects of this outbreak, even though we didn't have an answer to 
controlling it yet. This program that we had worked out was 
actually later a pattern for AIDS control in other cities. They 
used San Francisco as their model. There was City Hall on the 
top, because all the health department money came through City 
Hall, from the budget, which was approved by the controller but it 
was under the hand- -sometimes the fist- -of the mayor's office. 

The San Francisco Department of Public Health got its funding 
from City Hall, and therefore couldn't just say, "Nuts to you; 
we're going to do what we want. We'll use the money the way we 
want to." It's a line item budget, so anything that we had down 
for, say, typewriters in an office, we couldn't change to 
medication in the [AIDS] clinic [at San Francisco General] . At 
that time, we were beginning to fight for program budgeting, which 
would have given us more freedom. I don't know if they ever got 
it. They didn't have it when I left in 1984. 



54 



The Bureau of Communicable Disease Control then had two arms: 
the separate VD [venereal disease] and TB [tuberculosis] clinics, 
and the Bureau of Disease Control. My chief of the bureau was in 
charge of the VD and the TB clinics. They were free-standing 
clinics, and I had all the rest of the infectious disease. So my 
part of the work covered the AIDS epidemic. 

The San Francisco health department had relationships with 
UCSF, where Conant had the KS clinic. His clinic also 
communicated with CDC directly. Between his clinic and the KS 
[Research and Education] Foundation, we had put together our 
epidemiology group. That's the inclusive group [the KS Study 
Group] I told you about where we met every two weeks and talked 
about the latest things we knew about the disease. 

Then the department itself worked directly with the state 
health department, the California Department of Health Services, 
because we had to report communicable diseases to it. It got its 
information from us directly. We worked directly by phone with 
CDC, reporting in cases and getting from them reports, for 
instance, on the latest numbers of new cases in northern 
California or in Atlanta, or the latest theories coming from the 
men working in New York City. CDC had that; they were a 
transmitting agency as well as a research organization. 

Hughes: How did they release information? 

Dritz: We worked by telephone. It was very informal. Anything they 
wanted to, they printed in MMWR, but that would take maybe two, 
three, four weeks to come out. When we got Ammann's baby, I 
telephoned them that we had strongly presumptive proof that AIDS 
was transmitted through transfusion. They had that in the very 
next MMWR, which comes out weekly. 1 So they could work it fast. 

Then, I worked with Shirley Fannin in L.A. by phone. She was 
[deputy] director of infectious disease for Los Angeles County. 
Or through CDC with L.A. We worked together, and I found out what 
was going on there with them. 



*A. J. Ammann, M. J. Cowan, D. W. Wara, et al. Possible transfusion- 
associated acquired immune deficiency syndrome (AIDS) - -California. 
Morbidity and Mortality Weekly Report 1982, 31:48, 652-654 (December 10, 
1982). 



55 



The News Media 



Dritz: 



Hughes : 
Dritz: 



Hughes : 
Dritz: 



We also worked with the press and the broadcast media. The radio 
stations called in several times a day for the latest statement every 
time something new came out. My clerks became very, very blas6 about 
the TV people coming in with their lights and cameras to take 
whatever we had to give them. Randy Shilts, David Perlman, Charles 
Petit from the Chronicle; John Jacobs from the Examiner; and a 
reporter occasionally came from the gay papers, the Advocate and the 
Sentinel [San Francisco]. I've forgotten the names. 

Did you feel in general that their reports were balanced? 

If I read their reports and found they weren't, I told them, 
"Don't come in again." The big press, the Chronicle and the 
Examiner, did exemplary work. They were very careful. Sometimes 
they would call back and say, "Did I understand this right?" So 
they got it right. On the other hand, if we said, "This is off 
the record," they observed off the record. 

Did you have to tell some of the press not to come back? 

I called one, I remember. I don't remember if it was the Advocate 
or the Sentinel or the Bay Area Reporter. I told him that he had 
something wrong, and I'd like a correction please, and I got a 
snooty reply. So I said, "Just don't come back." Which wasn't 
really the best thing to do, because we needed newspapers that 
reached the gay community more than the Chronicle or the Examiner. 
But we had access to the Advocate and the Sentinel, and they were 
quite responsible. Now, the New York gay paper, the New York 
Native, was a great one, but they didn't deal with us at all. You 
know, in New York, the West Coast is the Hudson River. 



Private Physicians and Other Health Departments 



Dritz: We also worked with the independent physicians of the community, 
such as members of BAPHR, Bay Area Physicians for Human Rights. 
There were the individual gay physicians, the general physicians, 
the other departments of public health in the Bay Area. 

Alameda County health department worked with us a lot, 
because it was beginning to get a lot of AIDS cases in Oakland 
among the sailors in the Alameda Naval Air Station. There were a 
couple of gay bars there that were helping disseminate the 
disease. Dr. Bob Benjamin was the head of infectious disease--! 



56 



think he still is- -and he worked with us in the early days, 
finding out what we were finding out and adapting it to his needs, 
because his numbers of AIDS cases were much lower than ours 
originally. 

Then we worked with the individual hospitals. Ralph K. 
Davies Hospital, for instance, right off the Castro, had a lot of 
patients from the Castro as some of the physicians had their 
offices in the Davies Medical Center. There were also clinics 
there . 



San Francisco Coroner's Office 



Dritz: And then we had a lot of dealings with the San Francisco coroner's 
office. Boyd Stephens worked with us by phone a lot. The gay 
community had doctors and lawyers and real estate men, but it also 
had hookers and dishwashers and homeless people- -we didn't call 
them homeless at that time- -and people that were just found dead, 
who were brought into the coroner's department. Or they were 
coroner's cases, or they died under suspicious circumstances, or 
they were found dead in their home and there was no doctor 
present, so it automatically became a coroner's case. 

We were able to establish a modus operandi so that if Boyd 
Stephens suspected that AIDS was a factor in a death, even if he 
couldn't prove it because we didn't have a blood test for it yet, 
he would give us the information in case it could help us make a 
contact with some other case. This was all confidential, of 
course, because among doctors you don't give the information out 
except to those that are involved in the particular case. 



Dritz: We shared anonymous data among doctors, among the gay community, 
among the health workers. 



Confidentiality 



Dritz: Many of the gays were "out." They were known to be gay, and they 
didn't make any bones about it. If we asked them, "Who was your 
contact?" and if it was somebody they knew was "out," then they 
would tell us if they could. 



57 



On the other hand, many of the men who were openly gay in the 
gay community were gay only to other gays. If they lived in an 
apartment house that wasn't known by the management to be gay, 
they had problems there. They couldn't let the management know 
that they had AIDS. They couldn't have a hint come out that 
they'd been visiting a doctor, because if the manager guessed that 
they were gay, and they were going to a doctor, they were out on 
the street. 

You couldn't blame the apartment house managers for wanting 
to get a dangerous, deadly communicable disease out of their 
buildings. They didn't want it to infect anybody else. For one 
thing, they didn't want anybody else to get sick or they'd lose a 
tenant; but on the other hand, they also didn't want to have some 
other tenant get sick and say, "Now, you let us be exposed to this 
disease, and it's going to cost you everything you own, plus 
everything you can earn the rest of your life." 

So I could understand their point of view, and yet, couldn't 
see it. None of us could. You don't throw these people out on 
the street! What are you going to do with them? Conant and the 
KS Foundation found some way to get enough money to buy a couple 
of old Victorians where they could put these people who were out 
on the street. 



The HIV Antibody Test 

Dritz: Now, the other part of the confidentiality picture was that when 
we did have a test finally, we had a big problem getting the gay 
men to come in to be tested, because it was almost impossible to 
reassure some of them that the results would remain confidential. 
We finally worked out, especially in District Health Center 1-- 
that's right in the Castro just off of Noe and Market Streets- - 
that there would be pre-test counseling, so that they could be 
told what was going to be looked for, what might be found, that 
they would not get AIDS from being tested, that they could not get 
AIDS from donating blood, that they could not get AIDS from just 
being in the clinic there next to another gay man. 

Then the blood was drawn. Their name was not taken. They 
were given a number. The same number was put on the blood tube. 
They were told, "Hang onto this number. In three or four days,"-- 
I forget which- -"call us, give us this number, and we'll tell you 
what the test result is. If you lose this piece of paper with the 
number, we won't be able to tell you what the test result is. We 



58 



do not have your name." And they could see we were not writing 
down the name . 

They were also told, "If the test is negative, you're fine." 
We didn't know then that there might be a window period. Later 
on, we told them, "Better repeat the test in three or four months 
just in case you've just gotten infected and your blood doesn't 
show it yet. But if your blood is reported positive, we want you 
to come back in, and we will talk with you about the ramifications 
of this --what you can do, what you can't do, how you can protect 
yourself, how you can protect other people, what you can expect to 
happen, where you can go for medical and emotional help." We 
didn't really know what was going to happen, but we told them what 
we could. "As we know more, we can tell you more. Come back in 
if you want to, as much as you want. We'll advise you. We can't 
treat you." We didn't know then how to treat the disease. Later 
on, we could. 

Hughes: Was the return rate high? 

Dritz: In district 1, it was slow in starting, but they did come back for 
counseling. The district health officer, the late Dr. Hope Corey, 
felt that she could get cooperation from them in following up 
their course later on. And they could also be referred, if they 
wanted to, to Winkelstein' s group, San Francisco Men's Health 
Study, for follow-up for the course of the disease. He was trying 
to do a prospective study, starting with men who were apparently 
healthy, but we didn't know a lot of them were infected already. 
The study population was checked every few months on how its 
condition changed. 

The confidentiality issue finally worked out quite well, and 
we still have the anonymous testing program going on in the health 
department. There are two testing sites now. The important thing 
was not the test so much, because if they tested positive, it was 
too late to help them at that time. But the pre-test and post- 
test counseling were important to help them prevent getting AIDS 
if they turned out to be negative; to help them prevent giving it 
to somebody else, if they turned out to be positive. We were 
doing public health preventive medicine. The medical treatment 
was in the San Francisco General Hospital arm of the health 
department and at UC Medical Center. 

Hughes: Did you feel that these efforts at counseling were successful? 

Dritz: Well, it varied as people vary. A lot of the gay men responded 
very well, and we thought it did them some good. We didn't see 
the numbers of new cases going down, and we didn't know how some 
of them had been infected a year or two before, and there was 



59 



nothing we could do about that. Some of them you couldn't reach. 
Most of those who wouldn't have been helped by this program- - 
emotionally, intellectually- -didn' t even come in for testing. 
They didn't want anything to do with the health department; they 
didn't believe it would be confidential. "You're trying to trap 
us." Or, "Oh, what the hell. I'm not going to get sick. I 
haven't gotten sick yet; I'm immune." So they died. Too many, 
too fast, too young. 

The health department wasn't permitted to continue asking, 
like Bill Darrow and Dave Auerbach from the CDC had asked, "You've 
got AIDS. Who did you get it from? Who were you sleeping with in 
the last couple of months or so? Can you give us names?" That 
was how they got the name of Gaetan Dugas , our so-called patient 
zero. 

There was such an outcry for confidentiality, especially from 
the New York [gay] group: "You can't tell everybody we're gay." 
They wouldn't tell any of the medical people whom they had been 
with. Later, medical people were no longer permitted to ask, "Who 
was your contact?" 

Hughes: Did you do contact tracing? 

Dritz: Well, yes. Our VD clinic now was able to send an epidemiology 
inspector out to talk to positive cases with positive gonorrhea 
and other types of VD, and ask them, "Who was your contact? We 
have to find out who you got it from or who you might have given 
it to." That's the way to control syphilis and gonorrhea, and 
some of the other sexually transmitted diseases. They could ask 
that. We were told, "You can't ask them about AIDS." I don't 
remember whether it was '82 or '83, but the confidentiality fight 
just blew up. As a result, the notebook I had, full of all my 
AIDS data for a couple of years, which I left in the department 
when I retired- -it was their property- -was shredded to preserve 
confidentiality. 

Just as I was leaving, all of my data from that notebook was 
transformed into code for the computer. No names. There were 
birthdates, so that we'd have the age range of the patients. 
There was date of diagnosis, presumed date of infection, general 
zip code- -where they lived- -even occupation. No names. So the 
computer had all the data, but we couldn't go back to it to find 
out who it was if we had wanted to. 

Fortunately, the transfusion case, Ammann's baby, had been 
before all of this, so that the blood bank was able to give us the 
names of the thirteen donors who had helped transfuse the baby. 
Otherwise, we wouldn't even have been able to know for sure that 



60 



the baby was infected by a known case of AIDS who had already 
died. 

Hughes: What did you feel personally about the issue of confidentiality? 

Dritz: It hampered us. We could tell them, "We're doctors. We've taken 
the Hippocratic Oath. We swear to you we will not do you damage 
by giving your name out as a gay person." If we gave the name out 
of an AIDS person, it was assumed that he was gay. So we could 
say, "We won't tell anybody, but we have to know about you, and we 
have to know about anybody you might have given it to, so we can 
prevent it. We won't tell their name either, but tell us so we 
can help them. Tell us where you got it so we can tell that 
person" --it was he most of the time- -"that he has it, so he won't 
give it to somebody else. We can tell him how not to do it. But 
tell us who it is." If they wouldn't, that was it. 

Hughes: But you could ask? 

Dritz: Well, I asked informally. Later on, I couldn't ask. We just 
said, "Do you know where you got it from? You'd better go and 
tell him." But we couldn't ask him. And of course, he would or 
he wouldn't tell. 

Hughes: That removed a powerful epidemiological tool, didn't it? 

Dritz: Of course it did. That's one of the things that Don Francis was 
screaming about. But the confidentiality issue just tied our 
hands . 

Hughes: Don Francis found the same problem at the CDC level? 

Dritz: Of course. We all knew we were hampered with it. The newspapers 
occasionally would mention the confidentiality question. 

Hughes: Now, had confidentiality been an issue with any other sexually 
transmitted disease? 

Dritz: As I say, with syphilis and gonorrhea, by law we could go in and 
ask the man whom he got it from and whom he gave it to. We 
couldn't threaten him, but we could make it very strong that if he 
didn't tell us who it was, then whomever he gave it to would give 
it to somebody else, and he could give it back to him. But this 
wasn't so terrible, because with syphilis and gonorrhea at that 
time, one shot of penicillin and they were cured. Of course, now 
we have penicillin-resistant gonorrhea and syphilis. But the men 
knew that you went to the clinic, you got your shot, and you were 
all right. You could go out and play in the baths again. 



61 



With this AIDS, though, they knew that if you got it, in a 
couple of years you were dead. So they were much more cautious 
about telling us who they were with, because they didn't want to 
be responsible for anybody being "outed." It was just a mess. 



Gav Issues 



Hughes: Did the issue hang upon homophobia? 

Dritz: To a very great degree, yes --homophobia and a fear of death. A 

woman was afraid that the man next door who gave her dog the bone 
from his steak might have given her dog AIDS because he was gay, 
she thought. Because if the dog got AIDS, [she thought] the dog 
could give it to her. That isn't only homophobia; that is fear of 
death. I'm not laughing at these people. They didn't know 
whether the disease was transmissible or not, or how you got it. 
We were pretty sure we knew how, but then we were doctors; we were 
trained for it. And trying to put it out into the press, into the 
media, over the radio as we did, it still didn't register. 

We hear some politician during the election campaign, and we 
tell ourselves, "Oh, that's just politics. I don't believe it." 
And that's how some of the people in the city here, the 
heterosexual community, felt about the AIDS epidemic. Remember, 
there were so many gays in the city, they were so visible, and 
some of the men were so outrageously gay- -the gay parade, for 
instance, with its transvestites and so on- -that it turned off an 
awful lot of the heterosexual community that wouldn't have been 
too bothered by the presence of gays if there hadn't been so many 
and they hadn't been so aggressively "out." 

Yet, the gays were being aggressive because they felt so 
threatened, by the disease and by the increased homophobia which 
was a result of the disease. The publicity about it just stirred 
everything up impossibly. City Hall was right in the center of 
it, and City Hall depended on votes. Of the little over 300,000 
voters in the city, about 120, 000- -100, 000 let us say--were gay 
voters. The other 200,000 were splintered among the different 
communities- -the Asians, the blacks, the East Asians, the 
Hispanics, the Italians, all the other ethnic groups --the city is 
a conglomeration of villages. Now, they wouldn't all vote as a 
bloc, so the 200,000 votes were scattered. On anything that 
threatened the gay lifestyle, 100,000 would vote as a bloc, so 
City Hall had to be very, very careful. When some of the more 
vocal parts of the gay community were saying all the time, "Civil 



62 



rights, civil rights, confidentiality," City Hall had to listen. 
And that hampered us at the health department. 

Harry Britt, the gay supervisor, was very, very cooperative 
with us. He tried to help. He interpreted for us what the 
feeling of the gay community was. Yet he himself was only one of 
one group. The gays were splintered in other ways. Some of them 
were very vocal. Some of them were very quiet. There was a whole 
group of closeted gays, the upper-class gays, that we didn't hear 
from too much. There was the Alice B. Toklas Club; there was the 
Stonewall Club; there was the Harvey Milk Club; there were some of 
the unincorporated groups; there were the S&Ms (sadomasochists) ; 
there were the Gay Bath Owners Association of Northern California; 
there was the Tavern Guild, which was an association of gay bar 
owners and managers. All of these groups had their own agendas, 
and some of them could get together and some couldn't. 

Unfortunately for us, like the Moral Majority, there were 
fundamentalist -type gays in the gay community, too, who were very 
vocal, very reactionary, very entrenched for their own benefit. 
You couldn't blame them for this, but it didn't help anybody. So 
it was a mess. 



Meeting on Kaposi's Sarcoma and Opportunistic Infections. New York 
City. July 13. 1982 



Hughes: Let's turn to some of the meetings that you attended in the early 
years. The first one was the meeting on Kaposi's sarcoma and 
opportunistic infections in New York City on July 13, 1982, which 
was sponsored by Mt. Sinai and New York University schools of 
medicine . 

Dritz: Yes. That was a real meeting. For one thing, we didn't have any 
money. The city wouldn't pay for us to go. Paul Volberding and 
Don Abrams flew the red-eye. The meeting was to start at 7:30 
a.m. in New York. They got in probably about 5:00 or 6:00 a.m. on 
the red-eye. I flew the red-eye also, but on a different flight. 
I didn't know they were coming. We spent the whole day there in 
the auditorium. Presentations were I think fifteen minutes each, 
and three minutes for comments. They went through until noon. We 
had a working lunch, at which we learned from each other. 

At 1:00 p.m. we were back in the auditorium, and the 
presentations continued every fifteen minutes with three minutes 
for comment until 5:30 without a break, no coffee breaks, nothing. 



63 



I walked out of there on a hot July afternoon. My brains were 
fried. 

Here's some of what went on. [consults notes] Fred Slegel 
gave a definition of the problem. In other words, what is this 
epidemic we're dealing with? Because we still didn't know. Uas 
it cell-mediated? Was it an immunodeficiency? What are the 
factors? Was it immunology? Was it genetics? Was it lifestyle? 
Was there an incubation period? How do you manage it? How do you 
prevent it? 

Dave Sencer, who was then head of the New York City Health 
Department and had been head of CDC before that, was the moderator 
on the panel on epidemiology. William Foege, the director of the 
CDC, talked on surveillance and how the problem was increasing. 
Pauline Thomas spoke on surveillance in New York; Michael Lang on 
the immunological status. He was worrying, why don't we have KS 
or PCP or opportunistic infections in the sick group? Now, I 
don't know what he was talking about there; I don't know if any of 
us did. Is there a pre-existing cellular immunodeficiency? Do 
they have so many other diseases that the immune system is so 
knocked down by successive insults that it finally can't respond? 
Lang talked about his study of 103 gays who were "well." We 
didn't know then how many of them were already infected, but 
symptomless. 

And then, were nitrites being used? We tested them for their 
T-4s and T-8s [lymphocytes], and for the cytomegalovirus titer-- 
everything that was going on. Did this early diminution of the 
T-4/T-8 ratio indicate a prodrome? At that time, we didn't even 
know this . 

Michael Marmor had an article in the Lancet in which he 
matched his twenty cases of Kaposi's sarcoma against forty control 
gays. 1 When I talk of controls, we didn't know when they 
weren't. Some of them were controls; some were already infected. 
He found that there was no difference between the two groups in 
their ethnic distribution or the risk ratio. For drugs, the 
question was amphetamines, coke [cocaine] and ethyl chloride. I 
don't know what gays used ethyl chloride for. He asked how many 
sex partners they had per month, and so on and so forth. After 
that, he discussed what things were significant and what weren't. 

This was all on epidemiology; in other words, what's doing 
it? Jim Curran described the CDC program on the surveillance of 



*M. Marmor, L. Laubenstein, D. C. Williams, et al. Risk factors for 
Kaposi's sarcoma in homosexual men. Lancet 1982, 1(8281) :1083-1087 . 



64 



KS and PCP. Mansell of the University of Texas had similar data. 
[Alexander C.] Templeton, who had been in Africa, said that the KS 
and Burkitt's lymphoma had different distributions there. I think 
it was KS that's above 10,000 feet, and Burkitt's lymphoma below 
10,000 feet. Since that's the differentiating line between 
mosquito presence and lack of mosquito presence, maybe it was 
transmitted by mosquitoes. 1 That was exciting. It didn't mean 
anything in the long run. 

Templeton also said that you didn't get Burkitt's lymphoma in 
all the kids. It depends on the age distribution of the 
population at risk. We in San Francisco didn't have any cases 
yet, but shortly after that I had eight cases of Burkitt's 
lymphoma in San Francisco in gay men within nine months. So that 
went right back to what he said. 

Then Curran asked, "What about the Haitians? What are the 
risk factors among them? Is their voodoo a factor, since it draws 
blood?" And then he talked about the similarity of distribution 
of hepatitis B among these people, because a lot of the gays were 
infected with hepatitis B. But that's because it was also being 
blood- transmitted through traumatized rectal tissues, and we 
didn't know that then. Some of them were shooting up; we didn't 
know that either. In the first few cases, we didn't even ask, "Do 
you use drugs?" The questionnaire hadn't been developed. In New 
York I think 12 percent of their AIDS cases admitted using drugs. 
Later on, our numbers went up to about that, too. 

Then there was a section on the immunology. Dr. Erica Goode 
moderated that. Fred Siegel talking about various tests of 
pokeweed mitogen, the natural killer cells, the cellular 
production of interferon, the PHA [phytohemagglutinin] responses 
--all these things. You have to be a virologist really to have 
all of this clearly in your mind. They suspected that the 
cellular interferon was not being produced, and maybe that was 
something that was wrong, or maybe when it was not being produced, 
maybe that was "ominous." You see, we were almost talking Middle 
Ages here. It was the blind leading the blind, with a little hope 
there was a light at the end of the tunnel, or maybe it was an 
oncoming train. 

Michael Gottlieb then talked about his cases with a decreased 
percentage of helper cells and increased percentage of suppressor 
cells that's the T-4s and T-8s--what we call now CD-4s, CD-8s. 
He talked about immune globulin production, again the pokeweed 



1 For more on Burkitt's lymphoma, including its distribution in Africa, 
see the oral history in this series with John L. Ziegler, M.D. 



65 



cells. At the time some of the cases were beginning to develop 
large lymph nodes, gay lymph node syndrome, which Donald Abrams 
here then began to follow, thinking maybe this was a milder form 
of AIDS; maybe it was an early fom of AIDS; maybe it had nothing 
to do with AIDS but it was related somehow. He's got a big study 
going on with that now. We know now gay lymph node syndrome is an 
early manifestation of developing active AIDS. 

Then Tom Spira. He was important. He was the virologist for 
CDC. He talked about the gays and the Haitians and heterosexual 
patients, and the fact that gays' lymphocytes and leukocytes were 
down. The T-helper cells were lowest in cases who were sick, and 
they were going down in cases which just had the enlarged lymph 
nodes, et cetera. He was one of the first who gave us a fair 
picture of what the helper-suppressor cell ratio meant. 

Arye Rubenstein talked about his probable AIDS infants. He 
couldn't say they were children of infected mothers because we 
couldn't test for infection then. So perhaps it was genetic. He 
and Friedman-Kien also had reported something called the HLA-DR5 
gene, which was the same in epidemic KS versus classic KS cases. 
So maybe that wasn't a clue. 

Then the New York cases in blacks and Haitians versus 
Caucasian controls left some questions in their mind. This is 
genetics. Remember, this was ten years ago, and genetics has 
exploded since then. So this is not really medieval genetics, but 
it's very, very early Renaissance genetics, if you wish. Yet, 
that was the foundation for what we learned later. 

Then the panel talks: Roger Enlow speaking for New York. 
He's a gay doctor or a doctor with a gay practice, I don't know 
which. He talked about the gay lymph syndrome. We were getting 
too much data, too fast to tabulate. His general findings were 
the same as San Francisco's, as well as CDC's. And I won't go 
through all of my notes . 

Somebody called Fitzgerald was talking about the differences 
in the production of interferon. This is all to show you how 
little we knew and how many things we were considering- -thymus 
production, and alpha interferon levels. Would chemotherapy do us 
any good in improving the T-cells before and after the treatment 
for the KS cancer? In other words , we knew that when cancer 
patients were being treated with chemotherapy, their immune 
system, their T-cells, went down. It was in cases like that, that 
we found occasional PneuwocystLs pneumonia. The same occurred in 
Salvitierri's kidney transplant group at UCSF. When he had to use 
chemotherapy on his patients to keep them from rejecting the new 
kidney, they sometimes developed Pneuaocystis pneumonia. That was 



66 

the first clue we got that maybe these patients with Pneumocystis 
were also immunosuppressed. 

I would talk on the phone to three, four, five doctors a day 
about the AIDS epidemic, and about other things, too. I'd be 
talking about some other case, and they'd say, "Oh, by the way, 
I've got another case," and tell me a little about it. 

Hughes: People all over the country? 

Dritz: Well, here in San Francisco. About the other cities, I don't 

know. You see, we were such a tight-knit community here. Ve had 
already put together our network, because of the enteric disease 
transmissions that we had in this very visible gay community, with 
shigella and amoeba and hepatitis A and B, so we already knew each 
other, and we were used to talking to each other. I could just 
pick up the phone and say, "Tom, what are you using now for 
aggressive hepatitis B?" I won't use his last name; he doesn't 
believe ethical physicians should seek or accept publicity. And 
according to Hippocrates, he's right. 

As a matter of fact, about a year ago when I was in the 
neighborhood, I walked up to Tom's office. I asked him how it was 
going. He said, "Well, we're using AZT, but I'm finding after 
about twelve months it's no longer effective, and then the 
patients go down. They die sixteen, seventeen, eighteen months 
after diagnosis." 



Dritz: I could talk to Tom and then call Bud [Louis] Boucher, a private 
practitioner with a large practice in the gay community, and say, 
"Well, Tom says thus -and- so. What are you finding?" That way, we 
were up-to-date on what was happening here in the city, and the 
best information that any of us knew was being transmitted. I was 
the stirring spoon. In German they use the word "Kochleffel. " I 
was in every pot, and getting information distributed around. 
That was my job. 

You don't really want me to go on through all this meeting. 
There was Friedman-Kien, there was Goedert from the National 
Cancer Institute, Shearer on auto -immunity, mouse experiments they 
talked about, then the etiology panels all of this was still 
going on. Etiology, what's causing it? If you look at this, 
you'll see my scribbling is getting more and more illegible. 

Hughes: I can see why. 



67 



Drltz: Then Al Prince was talking on hepatitis B in the gays in New York, 
with a 35 percent increase among them. I could have told him I 
had a 70 percent increase among the gays in San Francisco in the 
preceding years. But you see, the New York group were spread 
through five boroughs. The doctors were spread all over the 
place. I imagine that maybe a doctor in Manhattan didn't 
necessarily have day-by-day contact with a doctor in the Bronx. 
I'm not sure; I don't know New York that well. They would meet at 
the medical society meetings, maybe. But if they had their own 
borough society, then maybe the word wouldn't get around so much. 

So if Prince saw a 35 percent increase in hepatitis in the 
gays in New York, maybe that was a delayed report at that time, 
whereas, when I had a 35 percent increase, I knew it as of last 
week. I'm not saying for me, but in our department, that's the 
way it could have and did work, because we were in the field. We 
were on the ground. 

Martin Mass said that a virus was more likely to be the cause 
than anything else. He ruled out nitrite drugs. He said, "We do 
know from some reports that sperm also decreases the level of the 
T-cell activity." So they were saying, "Well, these guys are 
shooting sperm into each other back and forth. Maybe that's doing 
it." It didn't turn out to be. 

When all of these things were finally put in on the computer 
grid- -a regression analysis- -forty reports against fifty contacts, 
the only thing that came up as significant was number of sexual 
contacts and type of contacts. 

Friedman-Kien here was reporting about the Haitians. He told 
about his sixty patients in New York. It was a very active scene 
there. 

Linda Laubenstein, a hematologist and oncologist, was very 
good. She used chemotherapy on things like leukemia and so on. 
She said she now had about seventy cases of KS at New York 
University, and she talked about Uganda treatment trials. She 
talked about how using vinblastine and blastomycin would give her 
fairly good results, but we didn't know that later this would drop 
down the immune system efficiency. 

Hughes: Did those drugs pre-exist the AIDS epidemic? 

Dritz: Yes. These were some of the newest drugs being used in cancer 

chemotherapy. And since we had KS as the earliest manifestation 
of AIDS, we began to use cancer treatment. What we didn't find 
early was that the cancer treatment made patients worse, because 



68 



Hughes : 
Dritz: 



Hughes : 
Dritz: 

Hughes : 
Dritz: 

Hughes : 
Dritz: 



it diminished the activity of T-4 cells; it dropped the T-4/T-8 
cell ratio. 

Oh, yes. Bijan Safai talked on immunological therapy. He 
was a cancer doctor at Sloan-Kettering. He had used interferon 
and thymosin, transfer factor, DCG--I don't even know what that is 
any more- -maybe he said BCG [bacillus Calmette-Guerin] , the TB 
vaccine- -mixed bacterial vaccines. He said, "This one gave no 
good clinical results, and that one gave mixed results, and this 
other one dropped the immune response, and that one maybe caused 
NK [natural killer cell] activity to increase and maybe it 
didn't." 

Was there a conclusion? 

When I came out of there, my brains were fried. All we knew was 
that a lot of questions had been raised, a lot of theories had 
been presented, a lot of data had been presented, which didn't 
come to any clear presumptive theory as to the etiology, the 
management, the prognosis, or the prevention of the disease. 

I walked home from 101st Street, down 5th Avenue to the 
hotel, which was on 54th Street. I stopped in at Rustermayer's, I 
think it was, and had an ice cream soda. I felt human again. 

Now, that same night, Paul Volberding and Don Abrams flew 
back to San Francisco on the red-eye, because they both had 
clinics at 8:00 the next morning. Now, this is devotion. I 
stayed over that night at my own cost and took an early flight out 
the next day, and because of the three -hour time difference, I was 
still at my office at 9:00 a.m. 



That's devotion too! 

Well, we had to do that, 
it. Just couldn't. 



It was so exciting; you couldn't miss 



How did you hear about meetings? 

Oh, I would be talking with CDC, or they would call or send a 
notice around to all the health departments and interested people. 

So very quickly the individuals interested in the epidemic were 
identified? 

Yes. This was the summer of '82; it was a year since the first 
cases had appeared. It was two, three, four years since the first 
cases had been infected, but we didn't know that yet. And it 
wasn't until I think the next year, when Winkelstein's San 



69 



Hughes : 
Dritz: 



Francisco Men's Health Study developed, that we realized that with 
the blood test that we had and the testing that Paul O'Malley got 
us to do on the hepatitis B cohort blood samples, the 6,700 blood 
samples still In the freezer at CDC, that men had been infected 
with this virus as far back as 1978. Since they were already 
infected in 1978, it meant somebody else had to have had it to 
infect them. And later, we saw there was a two, three, four --now 
ten- -year incubation period, maybe they'd been infected way back 
in '74 or '75, or earlier. 

Yes, the time of initial infection kept getting pushed back. 

That's right. In order for the individual to have transmitted 
AIDS to somebody else, he had to have been Infected in '78 or 
earlier in order for us to find out about it in '81 or '82. 



Medical Grand Rounds on AIDS. July 1983 



Hughes: Well, the next meeting you attended, I believe, was at UCSF in 
July of 1983. 

Dritz: Well, there were informal talks here and there. We were lecturing 
to the epidemiology class at UC Medical School and we were 
lecturing to the STD, sexually transmitted disease, clinic course 
at UCSF during that time. 

This medical grand rounds in July of 1983 was at Cole Hall at 
UCSF. It was announced as a special medical grand rounds: 
[reading] "The Acquired Immune Deficiency Syndrome, a multi- 
disciplinary enigma. Moderator, John E. Conte, Jr., M.D." He was 
chief of infectious disease at UCSF. There was only an hour 
allotted for it, I think. There were going to be six speakers and 
a panel discussion, so we were allotted fourteen minutes each. 
Not very much time . 

The first speaker was Art Ammann on the immunology; he was 
the chief pediatric immunologist at UCSF, and world-famous. He 
reviewed the immunological aspects of AIDS. 

Then I presented the epidemiology. In fourteen minutes -- 
around the world in fourteen minutes--! talked about the 
sociological aspects, the community needs- - 

[tape interruption] 



70 



Dritz: --the demography, that is, the distribution of cases, 

geographically and in different types of populations. I talked 
about the increase in the numbers of the gay population in the 
city as contributing toward the rapid dissemination of the 
disease, about their exposure to the enteric diseases first, then 
about the earliest cases of PCP and KS and the incidence. With 
all of these factors, I showed slides on how the numbers were 
going up, doubling every six months. And how our numbers were 
just one year behind New York's, and therefore we could expect a 
similar rise in one year. 

The CDC's case -control study showed us what the risk factors 
were. By now, I think we already had our regression analysis 
showing that frequency and intensity and type of sexual contacts 
were the significant contributing factors to dissemination of the 
disease. 

Hughes: That was the analysis that was so slow in coming because of the 
lack of federal money for a statistician? 

Dritz: That's right. We did the study in late '81, early '82. No, it 

was late '81, because we were already in Atlanta, testing out the 
use of the 24-page questionnaire before the end of the year. We 
were using it in early '82. It wasn't until '83 I think that the 
word came out about the results of the case-control study. 

To return to grand rounds, I talked about the etiology; what 
could be doing it? Here I talked about lab studies and the 
numbers of things we had tested against on that, using the very 
complex slide I showed you previously. I talked about what we 
were using as treatment and the results we were getting, or 
rather, not getting. 

I also talked about the possibility of cases among health 
workers, because they were being intimately exposed to the 
patients. At that time, in my whole roster of cases, I had 
fourteen cases in health workers, but they were all- -I didn't say 
they were all gay men, but I said they were all members of a risk 
group. There were quite a number of gay men among the nursing and 
the AIDS staffs in the various hospitals in the city. 

Then I gave them Andrew Moss' survival curves, based on the 
patients we had and the dates of diagnosis and the dates of death. 
There was some hope, I supposed, because eventually we were going 
to find out how to treat AIDS, and how to make a vaccine. It 
might take years, but we'd have it. And what was still needed was 
a better definition of the cases, because Burkitt's lymphoma 
wasn't included as an AIDS case. Toxoplasmosis, cryptosporidiosis 
were being reported and CDC was not yet using them as a definition 



71 



for AIDS. Therefore, if a patient only had one or more of those 
manifestations, he wasn't considered an AIDS case, and so he 
wasn't eligible for help from AIDS programs. 

The new definition that has come out now has increased the 
numbers of cases that are defined as AIDS, which means it's 
increased the cost to local governments for those who can't pay 
for their own care, and the cost to hospitals that have to take 
Medicaid patients. And as we're getting more effective treatment, 
we're maintaining the patients alive longer. Therefore, they're 
needing treatment longer, which means the cost of their 
maintenance is greater. AZT was costing patients $8,000 a year. 
Burroughs Wellcome dropped the cost of it because the market has 
grown bigger- -supply and demand, and aggressive demands from the 
gay community. 

The cost of the epidemic is wiping out cities' budgets. San 
Francisco is putting a tremendous portion of its budget into care 
for AIDS patients now, because patients just don't have any other 
resources. The churches have opened hospices for the care of AIDS 
patients. These are just places for them to die, but at least 
they're not dying on the street. The cost of care is going up and 
up and up . 



Stuart Anderson and Vitamin C 

Dritz: Did I tell you about Stuart Anderson and the vitamin C problem? 
Hughes: Why don't you mention it now? 

Dritz: In the gay community, there were some people--! don't think they 
were organized in a group who simply felt that the medical 
community was so homophobic that we were just pretending to treat 
them but were actually letting them die because we didn't want any 
gays to survive. One policeman who came into my office said, "Oh, 
hell, they're a big problem. I think we ought to take a flame 
thrower and just clean out the Castro (gay center in San 
Francisco)." A policeman in uniform! On the other hand, there 
were other policemen who would give mouth -to -mouth resuscitation 
without thinking twice, because that was their job. 

Anyhow, some of the gays felt that the doctors, the health 
department, the community didn't want to do anything except kill 
the gays. As a matter of fact, some of them claimed we had 
introduced AIDS in order to wipe them out. I don't know how we 
would have done it; we didn't know what the cause was yet. 



72 



Linus Pauling announced that 30,000 units of vitamin C every 
day would keep you alive --prevent you from catching colds or 
anything else. I don't know if he said it treats cancer, but it 
was just about that. He's a very, very famous, very, very 
marvelous mind, but I think he went off the deep end on that. 

Stuart Anderson, an aggressive gay, then came in to my office 
and said, "We're going to use vitamin C." He was walking up and 
down Castro Street telling the gays, "Don't go back to those 
doctors. They're trying to kill you. They only want to kill you. 
You've got to have vitamin C." He was using 30,000 units. He got 
quite a number of the gays to leave their doctors and go on 
vitamin C. Of course, they died- -a pity- -and he died a year 
later, too. 

But there was that kind of resistance, which was a corollary 
of the confidentiality resistance, so in several different ways, 
we were hampered in trying to get complete cooperation in the gay 
community. A lot of them believed us, did what we thought would 
help them, and cooperated in bringing us information. Without 
their cooperation, we would have been blind to developments. 

But at the same time, there were aspects that hampered us and 
maybe helped to contribute to the spread of the disease. I know 
the baths did. 



Lecturing on AIDS 



Hughes: You mentioned off -tape giving a Friday night lecture to gays in 
the Castro. When was that? 

Dritz: It was a very hot Friday night, so it must have been in September 
or October after the fog season in San Francisco. Probably 1981. 
They had asked me if I could come and talk. They were asking one 
or two other doctors to come, also. They wanted me to represent 
the health department. They said, "There is so much confusion and 
guys are saying so many different things. They're going to hold a 
big meeting there at the recreation hall behind the Gala 
supermarket off of Castro," and would I be willing to come in and 
talk on Friday night. They said, "I know it's a weekend, et 
cetera," but I had nothing else to do, and I was glad to help. If 
I had something else to do, I'd have gone to their meeting anyhow. 

I came in there, and every seat was taken. It was a 
gymnasium, and they had set up well over 200 folding chairs there. 



73 



Every one filled. I had brought my slides along. I think it was 
Bob Bolan who introduced the talk. 

I presented what I had to tell them: where it is, who's got 
it, what we think is causing it, how it's being transmitted, how 
we think it can be prevented, what we're using to treat it, the 
poor results we're getting, what we think is going to happen. And 
please stop doing these crazy sexual things! That's what's 
transmitting it. I said, "Whatever you're doing in the bedroom," 
--I wasn't going to say in the back room of the bars; I think I 
mentioned the baths--"! won't stand in your bedroom and shake my 
finger under your nose and say, 'Now, don't do that, you're going 
to catch something,' but I'm telling you here, now, that's how we 
think you're catching it. It doesn't go through the air. You 
can't cough it into somebody's face. You can't get it from a 
telephone or from shaking hands. But you can get it sexually, and 
if you can't stop this extreme sexual activity, at least cut it 
down so your Russian roulette gun will have two bullets instead of 
six bullets in the chamber. Because right now, the way you're 
going, you've got six bullets in the chamber." 

Hughes: Were they listening? 

Dritz: They were listening. They were listening enough to say, "Well, 

how do we know who's got KS? How do we know if we've got it?" I 
said, "Well, I didn't think there 'd be enough time to show all 
these pictures. I've got a whole bunch of pictures of KS . Do you 
want to see them?" They said, "Yes!" So my talk ran a little 
over time. They had to get out of the center at ten o'clock. I 
showed them the ten pictures, twelve, whatever I had, that Jim 
Groundwater had given me, taken of his own KS patients. I didn't 
name names, but they saw Simon Guzman; they saw Bobbi Campbell; 
they saw some of the other early patients. 

I showed them the different ways KS looks. If you've got a 
light skin, it looks pinkish; if you've got a dark skin or you're 
heavily tanned, it looks dark brown. This is what you'll find. 
You'll find it on you here; you'll find it there; you'll find it 
in your mouth. If you've got thrush (candidiasis) , look for KS in 
your mouth. 

Also, if you've got a cough and it just doesn't go away, and 
it's not a cold, and it's a dry cough, and you have fever, and now 
you're getting chills, and you're having night sweats, and you're 
losing ten pounds in a week and you don't even know why because 
you're not dieting- -all of these things mean get to the doctor 
right now, because you've already got it. "If you haven't got any 
of these symptoms yet, please don't let yourself catch it, because 
once you've got it, you've had it." 



74 



Learning to Recognize Opportunistic Infections 

Hughes: In 1981, getting to the doctor didn't really do very much good, 
did it? 

Dritz: No, but a lot of them didn't get to the doctor, because in 1981, 
they thought their KS "spots" were bruises or eczema. Doctors 
weren't so well aware of KS in San Francisco then well, the gay 
doctors were- -and they would prescribe antihistamine creams to cut 
down the eczema. Then when it didn't turn out to be eczema, it 
wasn't anything else, they finally did a biopsy and they learned 
it was KS. 

Some of them didn't know what KS was. I had to find out 
about it myself and do some reading. You never saw it here. If 
you had heard about it in medical school in dermatology class, you 
sat for an hour and a half asleep while they showed pictures. You 
walked into derm class, they shut out the lights, and they started 
to show pictures of what it looks like. Which right after lunch, 
isn't exactly electrifying. Same with x-ray class. I slept 
through x-ray. I had to learn it eventually, but that wasn't the 
way to teach it. 

A lot of us who had maybe seen one slide of KS and heard 
about it only in old men in the Mediterranean or North Africa, 
didn't pay much attention. We weren't ever going to see it here. 
Now, when the doctors in San Francisco got a report of KS , "Huh?" 
was the response. Then, after a while, they learned about it with 
a vengeance. 

Doctors were treating patients with a cough for bronchitis, 
because the chest x-ray showed just a bronchitis and later on a 
diffuse bronchopneumonia . Well, bronchopneumonia is usually a 
viral affair or a yeast affair. They didn't know that it was a 
Pneumocystis pneumonia, because you didn't see that except if you 
knew about Salvitierri's work in kidney transplants in UCSF, and 
that sometimes an immunosuppressed patient gets Pnewnocystis 
pneumonia. 

When I gave a lecture to the epidemiology class at UC on 
Pneumocystis carinii pneumonia and Kaposi's sarcoma, one of the 
students- -this is a third-year medicine class- -raised his hand and 
said, "How do you spell Pneumocystis pneumonia?" They hadn't even 
seen the term in their books. 

So we all got a real education on some of these obscure 
diseases, especially cryptosporidiosis, the diarrhea disease of 



75 



sheep. "How do you treat the sheep?" we asked an expert. "We 
shoot them." 



[tape interruption] 



The Health Department's AIDS Program 



Development of Program Components 

Hughes: Dr. Dritz is looking at one of her outlines which is titled, "San 
Francisco Department of Public Health, Department AIDS Program, 
1983." And it goes on for three pages. 

Dritz: Three or four pages in big type. This program developed 

gradually, step by step here, as the AIDS cases developed and we 
began to see what the problem was going to be. We didn't know 
from the beginning what it would be. It became a model for a 
city's approach to an AIDS outbreak, and later was adopted- - 
adapted, anyhow- -by New York, by Houston, by Miami, by Chicago. 
We heard that they were using different parts of this program, or 
they were using it as their model. 

First of all, we were concerned with active surveillance and 
treatment. We had an AIDS clinic for screening and outpatient 
treatment at San Francisco General, and we had the AIDS ward, 5B, 
there--it became a famous place for patients who were too sick 
for an outpatient regime. We cooperated with Marc Conant at the 
UCSF clinic, with San Francisco General, with John Ziegler at the 
Veterans' Administration Hospital, and also with the California 
Tumor Registry, under Eva Glaser. It was that registry that gave 
us the indication that the numbers of Burkitt's lymphoma cases we 
were seeing was way out of line with what they would have expected 
to see in the whole state of California in two years. 

We had a central case registry in our office, and we 
exchanged data with the state and with CDC also on their cases. 
We gave them our case names at that time, until we were forced to 
observe more confidentiality later. We also used a laboratory 
test for checking cytomegalovirus and adenovirus titers. At that 
time, we didn't know which virus was causing what, if it was a 
virus. And we kept a serum specimen bank on all of those bloods 
that we had drawn since 1980. 

CDC also had set aside, without realizing they were going to 
be so useful, the 6,700 bloods that had been drawn during the 



76 



hepatitis B vaccine trials, which were still in the freezers at 
CDC. We used those later in our retrospective study on how far 
back infection had been present and unsuspected. It was Paul 
O'Malley of the San Francisco Department of Public Health AIDS 
Activities Office who remembered about the stored bloods- -a major 
contribution. 

Besides the active surveillance and treatment, our department 
carried on research, in-house projects. There was this hepatitis 
B cohort study I told you about; the case -control epidemiological 
study with Moss at UC; we kept track of transfusion cases with 
Irwin Memorial Blood Bank. We did contact tracing in-house, just 
as we did for syphilis and gonorrhea, until the confidentiality 
issue closed that down. 

Hughes: Contact tracing stopped with the availability of the AIDS test? 

Dritz: It goes so far back, I can't say for sure now. You may find 
something in the literature on that. 

Then we were doing viral culture studies. Our laboratory was 
testing for beta microglobulins and every virus we could think of, 
including Epstein-Barr virus and cytomegalovirus and retroviruses , 
if there was any test for them, as a screening test for AIDS. 

This was summer of 1983, and it was about that time that Luc 
Montagnier and his group at the Pasteur Institute said that they 
had isolated a new retrovirus in their AIDS cases. But it wasn't 
until 1984, a year later, that Gallo and his group at NIH said 
that they had "the virus," unquote. And it wasn't until March of 
1985 that the federal government actually licensed a test for the 
AIDS antibody. 1 

Then, in addition to our active surveillance and our 
research, we had outpatient support. We had public health nursing 
home visits and counseling to AIDS patients. We had the community 
mental health services section of our department doing substance 
abuse counseling, and then we had our educational program, both 
for professionals and also for the lay population. Under 
professional education, we talked with hospital staffs, we 
developed guidelines for medical schools and hospital outpatient 
departments, and we had our education program for the political 
people, because politics in San Francisco was a real labyrinth of 
Minotaurian dimensions. 



R. Gallo, L. Montagnier. The chronology of AIDS research. 
Nature 1987, 326:435-436. 



77 



Hughes: Were these activities in addition to those of the committee that 
you described at the beginning of the session? 

Dritz: Yes. These were the activities of the department as a whole, 

through my bureau office. The committee was an advisory committee 
to the director of the health department. What I just described 
was a program which probably included some of what we had learned 
from the advisory committee, as we developed information on the 
needs of the patients and their health providers. 

#* 

Dritz: I should point out, at this time- -this was 1983 already- -the AIDS 
"staff" in my office still was me, one epidemiological assistant, 
who had been borrowed from the city VD clinic, and two clerks. 
That was it. 

Hughes: How many hours were you working a day? 

Dritz: Eight hours a day in the office, and then there were meetings in 
the evening and on weekends. I didn't feel that I was killing 
myself physically, but I was killing myself emotionally and 
intellectually, because I was so excited about the challenge. I 
had a tape recorder on my bedside table. I used to wake in the 
middle of the night and think, "God, what are we going to do?" 
Sometimes I would tape an idea, because I might forget it by 
morning. In the morning I'd play it and it wasn't any good 
anyhow. But you know, it got you by the throat. You couldn't 
stop. 

Well, anyhow, we had to deal with City Hall, we had to deal 
with the state, we had to deal with the federal government, and 
the feds included NIH and CDC. Now, City Hall governed our 
budget. City Hall got a lot of its budget from the state, which 
got its from the feds, and the feds didn't have any money. It was 
all being shot up into Star Wars and things like that. So the 
government took money from NIH, which ran CDC. If CDC needed more 
money, NIH had to take some away from the National Cancer 
Institute or from the NIAID [National Institute of Allergy and 
Infectious Disease] under protest. 

The piece of financial pie for the health services- -federal, 

state, and city- -was diminishing all the time. And yet the needs 

were exploding. So we had these problems with the politicos. We 
had to educate the politicians. 



78 



Education Program 



Dritz: And then we had our educational program for the lay population. 

One part was with the gay groups. We put posters in the baths and 
the bars, pamphlets everywhere- -it didn't mean anything. We had 
the community meetings; the Eureka Valley meeting is the one I 
just told you about. 

We had the press meeting with bath owners, in which Silverman 
tried to explain to them, "We've got to close the baths," and all 
they said was, "We are now organizing the Northern California 
Association of Bathhouse Owners, and you do anything to close the 
baths and we'll have a TRO, temporary restraining order, on you 
the next morning." 

Silverman knew we couldn't prove it was infectious; it was 
presumptive. An opposing lawyer would say, "Now, doctor, show me 
that this bath was the source of this man's infection." You know 
how lawyers are. So there was no point in closing the baths until 
we had proof. So we handed out pamphlets, and we had meetings, 
and we had the press meeting with the bath owners. 

Then I had an informal meeting with the Tavern Guild, which 
is the association of gay bar owners. All I could do with them 
was say, "Well, at least let me teach your bartenders how to talk 
to a gay man." A gay man would be having a beer at the bar, or 
whatever they have there. He'd say, "You know, a friend of mine, 
he's got this AIDS now, and I don't know if I'm going to get it." 
I would say to the bar owner, "At least, alert him that there is 
help, there is sympathetic help, in the health department. Go to 
the office of infectious disease, tell your story there. Or go to 
the AIDS clinic at San Francisco General. I've been told- -I 
believe themthat they're not going to give your name away." We 
tried to get through to the bar owners. 

Hughes : And did you? 

Dritz: Well, we talked with them, we got to them, we told the bar owners 
what to do. We couldn't stand there in every bar and see if they 
did it. But at least we hoped that some of the information would 
get through. You know, when you're working with a big population, 
it's not like God puts his hand down and everybody changes 
immediately. You can't pass a miracle. But you work step by 
step. 

With a disease, if you don't know what's happening, you treat 
the symptoms; at least make the patient a little more comfortable 
so his own body is more able to conquer it. In the case of AIDS, 



79 



his body couldn't conquer it, but maybe we could make him more 
comfortable. It's the same way with the population. You work 
where you can wherever there's an opening. You treat the 
symptoms. If the bartenders can be an avenue for help, you use 
them. 

We also worked with the heterosexual, the general, 
population. We had an interesting problem with employers. We 
worked with Wells Fargo Bank, Bank of America, Levi Strauss, 
Pacific Telephone. The personnel manager at Wells Fargo called us 
and said, "We're having a problem." I remember this very clearly. 
"One of our men has been out with Pneumocystis , and the doctor 
says he can come back to work now. But we've got 3,000 employees 
here in the building, and they're threatening to strike if he 
comes back. Can you help us?" This was part of the AIDS 
hysteria. 

I asked him if I could meet with him and his subordinates in 
the personnel department, and I would tell them what I could. I 
spent a whole afternoon with them in their offices, telling them 
everything I could about AIDS- -epidemiology, etiology, everything 
we knew- -how it was transmitted, how we were pretty sure it was 
not transmitted. One of them said, "Can you guarantee we won't 
catch it?" I said, "Nobody can guarantee you anything. Can you 
guarantee I won't be hit by a car when I cross Market Street? I 
don't know if I can tell you the odds [for getting AIDS] are the 
same or less. I can't guarantee it, but we haven't had any 
reports that AIDS can be casually transmitted, and we know of no 
secondary AIDS cases in close household contacts of AIDS cases 
unless the contacts are also of high-risk behavior." 

At the end of the afternoon, all of his division heads were 
experts on transmission of AIDS, unquote. The next day he called 
me and said, "We're having a meeting with all of the employees. 
Would you come to the meeting?" I said, "I can't. I have to be 
in Atlanta this day. But I'm sure you can tell them what you need 
to." I would have been there if I hadn't been in Atlanta. 

He called me back the next day. He said, "We had a meeting. 
I told them what you told us. My division heads told them what 
you told us. We said we believe what you said. They took a vote, 
and they're going to permit him to come back to work, but they'll 
put him in a little different division, and his desk will be near 
the window, a little further away." That's all right. When they 
said, "You can come back to work," this man said to himself, "I'm 
living again!" It made that much difference. 

He died six weeks later, but he had been able to come back to 
work, and they didn't strike. If they had struck, some of the 



80 



other companies might have struck also. I was able to give other 
companies some counseling over the phone. We were able to head 
off strikes and hysteria in large organizations. 

Hughes: What an accomplishment! 

Dritz: You do what you can. 

Hughes: You were doing a lot. 

Dritz: Well, to put it crudely, that's what I was getting paid for. 

Then we worked with neighborhood associations, including 
mine, the Crestlake-Pinelake Park Association. Also the Haight- 
Ashbury group. I wasn't called by the Fillmore [District]. I 
talked with the Castro and Noe Valley groups. As I said, this 
city is a group of villages, and I was able to talk with a lot of 
them. 

There was a group down in Bayview-Hunter's Point, way off by 
the bay, where they used to have quonset huts. It was a colony of 
Hawaiians and Polynesians. They were terribly worried about AIDS, 
and they had a language difficulty. I was able to talk with them 
at their Assembly of God meeting house. The minister interpreted 
for me. I was able to tell them what was happening, where, and 
how. The minister turned to me and said, "You don't have to worry 
about that, because we don't have any homosexuals in our group 
here." I said, "Well, that's fine. I hope you don't." I don't 
know if he did or he didn't. On the other hand, the Japanese 
people had also said, "We won't have any AIDS here; we don't have 
any homosexuals." They do. 

Hughes: Were these communities concerned as a result of media coverage of 
AIDS, or did they think that they had a particular risk for AIDS? 

Dritz: I think they were just scared. For one thing, they saw themselves 
as aliens in a strange land. They were set off because they 
looked different. A gay man can pass. A Jew can pass. An Arab 
has a little darker skin. A Korean cannot pass; he looks 
different. These Hawaiians and Polynesians looked different; they 
were aliens. A lot of them had a language problem. They were 
fairly recent immigrants. 

Hughes: Had your reputation spread so that when a group wanted a speaker, 
they asked for Dr. Selma Dritz? 

Dritz: Well, Dave Perlman once said at one of Silvennan's advisory group 
meetings, "When we need information, we call poor Dr. Dritz. She 
gets all the calls. Everybody knows Selma." The radio stations, 



81 



the newspaper people, the TV people called my office because they 
knew the information was accurate. Many times I think they might 
have called Silverman's office, and he or his secretary would have 
directed them to me. 

Hughes : Your name was out there . 
Dritz: Oh, yes. They knew me. 

Hughes: I know that from going through the newspaper clippings on AIDS in 
San Francisco. 

Dritz: Oh, there were some before that. Our Legionnaire's disease 
outbreak put me in the paper, and our infectious hepatitis A 
outbreak- -that was the famous tofu salad mystery in San Francisco. 
I won't go into that because it has nothing to do with AIDS. But 
it was part of getting the health department known as interested 
in controlling infection without damaging people, that we were 
friendly. Our pictures were in the papers often. 

We put out pamphlets targeted for every group in the 
he tero[ sexual] community, in English, Chinese, Spanish, Tagalog-- 
that's for the Philippine community- -and we had translators for 
Korean and Thai. We put our material out in comic -book style, 
with big lettering so that it would be easily assimilated. We put 
out pamphlets in different languages- -for kitchen sanitation, for 
food handling, for transmission of airborne diseases. We didn't 
put them out in Japanese. The Health Education Bureau believed 
that Japanese in San Francisco had mastered English. But all the 
others went out in multiple languages, so our AIDS literature did, 
too. 

We put out guidelines for the workplace which had been set up 
by CDC. We put out "AIDS for the General Population"- -you can 
shake hands, you can use the same telephone, things like that. 
Questions from the public always came in to my office. I'd answer 
them on the phone. Then I lectured at the state and local 
colleges, too. 

Hughes: Was the content of the AIDS pamphlets changed according to the 
targeted population? 

Dritz: I don't think so, no, except for the gay community. 

Now, we knew that AIDS could be transmitted by blood; we knew 
that it could be transmitted by sexual contact. We were beginning 
to see heterosexual cases. So we mentioned these sources of 
infection, and we didn't use the word "promiscuity," but we 
implied it, and said that is the major risk. The more times you 



82 



expose yourself to a risk, the better the chances are that one of 
those times, it will hit you. We used the term Russian roulette: 
"The more times you play Russian roulette, the more chances you 
have to get that one bullet in your head." 

Hughes: You avoided the term "promiscuity" because it was pejorative? 

Dritz: That's right. But we said, "If you have a lot of sexual activity 
with a lot of people, and a lot of very traumatic--" we didn't use 
the word traumatic "--if you have sex in a way that damages your 
skin or your tissues, you transmit body fluids, semen or blood, 
you have to be careful." You wouldn't use a word like semen with 
a group that was a very orthodox or fundamentalist religious 
group. 

Hughes: So you'd leave it at "body fluids?" 

Dritz: Body fluids, yes, or just "too much sexual activity, careless, 
frequent, with many, many people," instead of "promiscuity." 
"It's not so bad to have many contacts with only one partner. 
Your chances of being infected depend on whether that partner is 
infected. But if you have one contact with each of many partners, 
among them you're going to find somebody that's infected, and 
you'll get it." That was about the way we put it. 



The Department's Ties with Various San Francisco Organizations 



Dritz: Our program also cooperated with allied groups. There was the KS 
[Kaposi's Sarcoma] Foundation, the Shanti Foundation for home 
finding and counseling of patients and others, the Home Health 
Service, and the VNA, Visiting Nurses Association. Haight-Ashbury 
Clinic was good, because it sent us drug-associated cases. David 
Smith--! think he's still in charge there did a wonderful job. 
That was a drug treatment program that started in the Summer of 
Love, the sixties, and it continued from then. 

Some of our contacts with the gay community started long 
before AIDS, with those drug-associated cases from the Haight- 
Ashbury Clinic. I had forgotten that. Many of the gays who first 
came to the city when the gay community began to expand lived in 
the Haight-Ashbury. The drug junkies --to use a pejorative term 
there- -in the Haight-Ashbury were outsiders. The gays that came 
in were outsiders, too. They gravitated to the other outsiders. 
They were in the Haight-Ashbury first. Later, they spread into 
the Castro, which is not so far from there. 



83 



So our first contacts, through the drug-associated cases in 
the Haight-Ashbury, gave us contacts with some of the gays, too. 
They got to know the health department, even if they weren't on 
drugs . 

Then we worked with Children's Hospital, a general, not a 
pediatrics hospital, which instituted one of the early AIDS 
treatment programs for gay men. We worked with the Pacific 
Medical Center's men's clinic. The two hospitals have since 
merged. The men's clinic was for sexually transmitted diseases, 
and of course AIDS became one of those. We worked with the Gay 
and Lesbian Health Services Coordinating Committee. We had weekly 
meetings at first and later monthly meetings with them on AIDS. 

And we worked with the Irwin Memorial Blood Bank on 
transfusions, and we worked with BAPHR, Bay Area Physicians for 
Human Rights, because those were the doctors who had the largest 
concentration of gay patients. There was a large number of gay 
doctors in that group, although there were other gay health 
workers and non-gays there too. 

Then the last was our AIDS advisory committee, with members 
from the health department, San Francisco General, UCSF, Irwin 
Memorial Blood Bank. Herb Perkins, the medical director of Irwin 
Memorial Blood Bank, was on the AIDS advisory committee, as well 
as John Ziegler from the VA Hospital, and representatives from 
BAPHR and the San Francisco Medical Society. That covers the high 
points of our city-wide AIDS program. 

Hughes: Do you think any other health department came close to having that 
number of institutional contacts? 

Dritz: I have no way of knowing, but I know that a lot of them were using 
San Francisco as a model, and CDC told other cities about our 
program, too, because I was on the phone with them all the time. 

Hughes: AIDS being an infectious disease was also a reportable disease. 
How was compliance? 

Dritz: Well, AIDS itself in the beginning wasn't reportable. Later on, 
the state declared it as a reportable disease, and by law, it had 
to be reported, and doctors reported it. AIDS patients were 
reported, because it was a sexually transmitted disease. AIDS- 
infected persons who were not actively sick with AIDS were not 
reported, and they still aren't reported. 

Hughes: Even with the new expanded definition? 



84 



Dritz: Even with the new definition, being infected with the AIDS virus, 
having a positive AIDS antibody test, is not reportable. That is 
one thing that hampers us. For political reasons, civil rights 
reasons, such cases are not reportable. So all we can do is urge 
people that we know are AIDS-positive not to expose others and to 
go for medical care as soon as any symptoms develop, or medical 
advice before symptoms develop. That's what the AIDS post- testing 
counseling is designed for. 



San Francisco Men's Health Study 



Hughes: Do you want to comment on the San Francisco Men's Health Study? 

Dritz: Well, I can to a degree. That is Warren Winkelstein's study, 

which started with a door-to-door survey in zip code 94114- -that's 
the Castro and Noe Valley- -to find where unmarried gay men lived 
who would be willing to be part of a study. That's a prospective 
study. The men are asked to have a confidential AIDS test. At 
first they weren't asked, because we didn't have the AIDS antibody 
test then. This was now ten years ago. 1 

They are interviewed, I think every six months, maybe it's 
more frequently, and they and their physicians are asked to keep 
in touch with the program. The program follows them statistically 
as the symptoms develop. We now know, based on that study, that 
from the time a man enrolled in the study with no symptoms at all, 
he then developed what looked like a severe flu and got over it; 
then weeks, even months later, he developed enlarged lymph glands. 
That lasted for a month, year; it varied. 

When the lymph gland subsided, he thought he was getting 
better. After that, real AIDS by the old definition developed. 
So we now have a case history of how the disease progresses, and 
much faster than when Robert Koch worked perhaps ten years seeing 
how a case of TB developed. 

I sat on Winkelstein's advisory committee until I retired. 
We tried to work out how to analyze one symptom versus another, 
how to get money for a machine that would do T-4 and T-8 counts, 
which we didn't have money for. CDC said maybe they could get us 
some money, but they would monitor and run the machine, and it 
would be their program. Winkelstein and the rest of the committee 



Winkelstein's study began to recruit subjects in 1984. 
history in this series with Winkelstein. 



See the oral 



85 

said, "No way, this is our study. We want to keep track of our 
own patients here and know what's happening." So there was a lot 
of infighting. 

About that time I retired [1984], so I don't know what 
happened. But I do know that the study defined the course of the 
disease, which is different from the retrospective study of the 
hepatitis B cohort. They had bloods of 6,784 persons who had 
taken part in the hepatitis B vaccine trials, which they now 
tested for the AIDS antibody after March of 1985 when they finally 
had an antibody test. They found that 4 percent of the bloods 
drawn in 1978 were already positive. 

Winkelstein was able to follow every few months the 300 or 
400 who hadn't yet been infected, and they found that the 
infection rate increased and increased and increased, so that they 
had about 60 percent positives by 1984 or 1985. 

A prospective study tells you a lot more certainly than a 
retrospective study. Retrospectively, we could tell how many 
people had been infected back in 1978. We didn't know how they 
got infected, and what happened to them in the course of it. Most 
of those had died off by the time we got to them. But when you 
start prospectively with people who aren't yet symptomatic, you 
follow how the disease develops in them- -and also, you can define 
the probable degree and distribution of future cases. 

So a prospective study can give you clearer information on 
where you're going and what you can expect. On the other hand, 
the retrospective study tells you where you've been and how much 
is already bad, that you have to gear up for. 



The Bathhouses 

[Interview 4: July 8, 1992] ## 

Hughes: We've talked tangentially about the bathhouse issue, but I thought 
it would be well to go through it sequentially. As I understand 
it, the issue began to simmer early in 1983. Is that your 
perception? 

Dritz: Well, the battle to close the bathhouses began to simmer then, but 
we were aware of the problem and trying to do something at least 
sub rosa to diminish it long before that in fighting the STD 
diarrheal diseases there. In '82, we were aware of Gaetan Dugas 
and the connections between him and so many people that he met 



86 



here in San Francisco at the baths, and his open announcement 
that, "Well, I'm off to the baths tonight, and there's nothing you 
can do about it." He came to my office and said, "It's my right 
to go where I want to." 1 

We were becoming reasonably sure that this was a disease 
caused by a transmissible agent. It seemed to be concentrated in 
gay men who were very sexually active. (I'm leaving out the 
question of the hemophiliacs.) The place where they could be most 
sexually active, most traumatically active, was in the baths. 

We felt that, as with any transmissible disease, you try to 
diminish the numbers of contacts between the infected person and 
uninfected people. That was why we had quarantine for smallpox 
and chicken pox and scarlet fever, for instance. We couldn't 
quarantine the men here, because we couldn't prove that this 
really was an infectious disease, and even if we knew it was an 
infectious disease, we didn't know what was the infecting agent 
yet. 

We became very unhappy about the baths . The bars had 
activity rooms in the back, the bookstores had activity rooms in 
the back, but the baths were the ones that were the most openly 
irritating to any epidemiologist, any physician. 



Meeting with the Bathhouse Owners, 1982 



Dritz: Some time in mid- '82, late '82, Dr. Silverman finally called a 

meeting of all the bath owners in San Francisco. I think he even 
had the manager of the Water Garden, down in San Jose, which I was 
told concentrated on urine transmission. But that was not in my 
San Francisco County jurisdiction. Glory holes were another 
inventive variation. 

The Club Baths, the back room of the Mine Shaft, which was on 
Market around 15th Street that one's gone, fortunately- -the 
Ambush and the Jaguar bookshops: these were all places for rapid 
transmission, effective transmission, among many people. The more 
contacts a man had, the more opportunities he had to be infected, 
the more the odds were that one of his contacts would infect him. 



: For a press account of Dugas' role as "Patient 0" in the transmission 
of HIV, see: "Patient tracked as carrier of AIDS." San Francisco 
Examiner, March 3, 1984. (Archives of the Gay and Lesbian History Society 
of Northern California [GLHS], AIDS clipping file, folder: AIDS 1-3/84.) 



87 



Well, Silver-man met with the bath owners- -fifteen or twenty 
men. I was there. It was a hot meeting. Silverman tried to be 
politic, calm. He was a very, very good administrator and a good 
public health man. But these people came primed for battle. He 
tried to explain the difficulties and that if they could at least 
tone down the opportunities for infection, raise the level of 
lighting in the "orgy room" where 100 men could have 
indiscriminate contact without even knowing who they were being in 
contact with, if they could take the doors off the cubicles, cut 
down the privacy a little tiny bit-- 

They wouldn't have it. There was table -banging, there was 
anger, and the spokesman for the group said that they were 
organizing the Northern California Bath Owners Association, that 
would include, I think, Marin County, although there wasn't 
anything much there that we knew of. There were some active bars 
in the East Bay, dealing mostly with sailors and staff from the 
naval air station there. And there were all the baths here. They 
were really centralized here in San Francisco. The major gay 
population was here in San Francisco. 



Relying on the Gay Community for Information 

Dritz: A few days, perhaps a week, after that, I had word that Gaetan 
Dugas was active. I have to point out here: if we hadn't had 
rapport with the men of the gay community, not only their 
political groups but the men themselves, we would have been blind, 
because they brought us information. We got word that, "Gaetan 
Dugas is out again, and he's being extremely active." There was a 
little risk in this news, too, because we couldn't always be sure 
that the information that was coming to us was really true. 

More than once, my chief would point out, "Well, yes, maybe 
he's f ingerpointing that man, and that man is really doing things 
he shouldn't do. But maybe also he's not only doing them, but 
this guy is f ingerpointing at him because they were lovers and 
they had a fight and he wants to get him in trouble." There were 
informal members of what they call the Street Ministry, one or two 
or perhaps three men who wore clerical garb and a cross. They 
were gay men who said they were trying to bring God to the men in 
the community. We got a call from one who said, "Father John said 
this man's doing something terrible. You ought to really take him 
in and just lock him up." We got in touch with that man and he 
said, "Oh, we're lovers. We had a fight." 



88 



So there were different things that we had to be aware of 
here, aside from the fact that we were trying to do epidemiology 
and trace down a serious disease. That could have skewed our 
ability to get a real answer to the question, just as our case- 
control studies were skewed we didn't know itbecause we thought 
we had matched gay controls who were not ill. We didn't know that 
maybe 10 percent of them were already infected and coming down 
with AIDS. So everything we were getting was Alice in Wonderland 
with a warped mirror. However, we did make a little progress. 



Threat of a Temporary Restraining Order 

Dritz: Then, a few days after I had word about Gaetan Dugas' actions in 
the baths, I began to talk to some of the doctors in the 
community. Did they know anybody that we could contact in 
connection with the baths that wouldn't be so aggressive, abrasive 
actually? One of the baths owners- -of the Cauldron, I think- -came 
up to my office. He banged on the desk and said, "You can' t close 
us up . " I said, "I'm not thinking of closing you up. I'm trying 
to figure out how to keep people from getting sick at your place, 
if they do go." 

He said, "We're a business, we've got a license, and you 
can't close us up. If you close us up, the next morning I'll have 
a TRO [temporary restraining order]." I had already called the 
city attorney's office [November 1983] to ask about our chances to 
close the baths and have them stay closed, and they said, "You 
have to be able to prove it." I talked to them again, "He's 
threatening to TRO." Ed Bacigalupi, who was the attorney for the 
health department in the city attorney's office, said, "You'll 
have to be able to prove to the judge that that is a definite 
health hazard, but the information you have is only anecdotal. 
You can only tell the judge that some men go to the baths, and a 
lot of men are active, and a lot of people have the disease. That 
wouldn't be sufficient information to close up a licensed 
business . " 

Hughes: But that's what you wanted to do? 

Dritz: We wanted to close them, yes. That was one place where there was 
the most open and the most frequent, the most voluminous, contact. 
And contact for an infectious disease is the sine qua non for 
transmission. 

Well, it went on for more than a year. Silverman talked 
about it, and then there would be a meeting, and then of course 



89 



the meeting was postponed until next month, and then somebody 
couldn't come to the meeting, so it was postponed for another 
couple of weeks. Then they couldn't come to a conclusion, so they 
decided to organize a subcommittee to look into this in more 
detail- -you know how organizations go. It dragged on and on. 



Open Hearing at the Health Department, March 30, 1984 

Dritz: Eventually, Silverman decided that he really had to close the 

baths; expecting the gays to stop patronizing them didn't work. 
So we put out word that he would have an open hearing when he 
would announce what he was going to do about the baths. That was 
the time when everybody met in Room 300 at the health department 
at 101 Grove, including three nude gay men, wrapped only in towels 
around their middles, carrying a sign that said, "Today the baths, 
tomorrow the ovens." 1 They screamed about their civil rights-- 
which was a justifiable fear for them, but it didn't balance the 
risk to other members of the population. I went into the meeting 
too, waiting to hear this announcement. 

In the meantime I had had a couple of calls from different 
men in the gay community. They knew that the meeting was 
scheduled for this particular day. They said, "Some of the guys 
are saying they're going to kill him"- -Silverman. I had to warn 
him. I called his office. I said, "Now, this is what I'm 
hearing. It's probably not so, but I would be remiss in any kind 
of duty I owe to the department or to you if I didn't tell you 
about it." 

So we waited for about an hour at that meeting in Room 300, 
and it got more and more restless. The press was there, members 
of the health community were there, members of the gay community 
and politicians were there. Finally, after an hour, Silverman 
walked in- -through the back door, all the way to the front, to the 
podium. This was a big auditorium. He was bracketed by security 
men. I was glad to see that, because the meeting was very scary. 

He got up on the platform, and we realized that he had been 
talking in his private office right next to Room 300. There were 
representatives of City Hall there, too. I think [Supervisor] 
Harry Britt was there. Apparently, an hour's talk hadn't brought 



1 See the article and accompanying photograph: Randy Shilts. 
"Silverman delays on gay bathhouses," San Francisco Chronicle, March 31, 
1984, p. Al. 



90 



any results, because when he got up on the platform, he said, "I'm 
sorry to tell you, but I will not make an announcement about the 
baths today. I'm putting this off for a week." And that was it. 

Hughes: What had happened? 

Dritz: Well, the big fist from City Hall had come down. They wanted the 
baths closed, but they wanted Silverman to make the announcement 
so that City Hall, the mayor's office, would not be politically 
responsible. On the other hand, Silverman just hadn't felt 
earlier that it would work that way. He had very strongly felt 
that to close the baths would simply disseminate the problem, that 
the men would find some other places to go, although the baths 
were the most effective place to get the most number of contacts 
in the shortest number of minutes. Minutes, actually. 

I didn't get to ask him too much in detail. It was a very 
tricky question. We were all very busy with other things. So all 
his intimate thinking about it wasn't evident. But what he had 
said to us --earlier in the advisory committee, in the off ice --was, 
"The gays have got to want to stop this themselves. If we stop 
it, they'll just find some other place to go. We've got to 
convince them that it's their responsibility; they've got to stop 
this. If it isn't on their own initiative, on their own desire, 
it won't work." But they didn't stop. 



Bathhouse Closure, October 9, 1984 



Dritz: Larry Littlejohn was an activist there. I didn't like what he was 
doing; I didn't like what he said, but that's aside from the 
point. He was pushing hard to close the baths, probably for 
political reasons, because, as I told you, the gay community was 
splintered on the issue of bathhouse closure. 1 The responsible 
ones --those who I think were the responsible ones --wanted to close 
the baths. The very aggressive ones wanted to have nothing 
interfere with their utter freedom to do anything they wanted in 
their own way, and their own way was to reassert their freedom to 
be actively, openly gay, any time and any way they wanted to. And 
that was their right, as long as it didn't kill other people. 



1 In March 1984, veteran gay organizer Littlejohn announced sponsorship 
of a city ballot initiative to close the baths. See: Randy Shilts. "Gay 
campaign to ban sex in bathhouses." San Francisco Chronicle, March 28, 
1984, p. Al; Randy Shilts. "After shutdown order comes." San Francisco 
Chronicle, October 10, 1984, p. A4. 



91 



Littlejohn made an announcement to the press that if the 
baths weren't ordered closed by a given day, he was going to 
arrange for an initiative to be put on the ballot to close the 
baths. Then we would see exactly who wanted what. Well, that 
seemed to be the final blow, because if it became an initiative, 
and the majority of the people voted to close the baths, that 
would be a black eye for the health department for having delayed 
closure. It would be a black eye for City Hall, too, because the 
people would have had to say they wanted the baths closed. On the 
other hand, if the voters voted to keep them open, then our hands 
would be completely tied. 

Hughes: So there was no way of winning, was there? 

Dritz: That's right. It was a no-win situation. So Silverman ordered 
the baths closed. 

Hughes: Largely because of this initiative? 

Dritz: Well, that finally forced his hand. Eventually, he would have had 
to order them closed. He had said previously to the bathhouse 
owners, "You must raise the level of lighting and put up notices 
saying the surgeon general says that this is dangerous to your 
health," or something. But nobody would have paid any attention. 

If a man goes in to a bathhouse and pays his ten dollars , 
he's going to have his ten, fifteen, twenty contacts. He isn't 
going to say after reading the notice, if he could even see it on 
a dark back corner wall, "Give me back my ten dollars," and the 
bath owner isn't going to give it back and take back his towel. 

Closing the bathhouses didn't do a lot of good. One of them 
reopened the next day to challenge Silverman. A few of them went 
out of business. The first one was a leather club, which finally 
went out of business because of dropping business. The newspaper 
had a big picture of the different equipment that the bath owner 
was trying to sell- -chains and slings and- -oh gads, forget it. 
The publicity about closure helped wake up some of the more 
complacent gays. 

Hughes: Did you make a deposition regarding bathhouse closure? I know 
Paul Volberding and others did. 1 



Declaration of Paul A. Volberding, M.D., in support of a temporary 
restraining order to close the bathhouses, October 10, 1984, Superior Court 
of the State of California in and for the City and County of San Francisco. 
(Dean Echenberg papers, San Francisco Department of Public Health, Bureau 
of Epidemiology and Communicable Disease Control, drawer: bathhouses, 



92 



Dritz: No. If that had been necessary, it would have been the director 

of the department who was asked. I was his subordinate, and so he 
would have spoken for the department. I wasn't asked. Now, Paul 
Volberding could be asked, because he was running the AIDS clinic 
at San Francisco General. Incidentally, he was doing a 
magnificent job. But I wasn't at the top levels. 



Divided Opinion in the Gay Community 



Hughes: How did BAPHR feel about closing the baths? 

Dritz: Officially, it wanted to close them. It was a large organization 
of chiefly gay doctors and other health workers, but it was not 
all gay. They were a bit splintered, but as physicians, they had 
to feel responsible for protecting the lives of their patients and 
the population that they serve. So they officially said, yes, 
it's a better idea to close the baths. I can recall perhaps only 
one or two that openly said, "We've got to protect our civil 
rights." Most of them were medically responsible. 

Hughes: An article on the front page of the Chronicle on March 30, 1984, 
said that Supervisor Harry Britt and fifty gay businessmen, 
physicians, and other political leaders had signed a statement 
asking Silverman to "temporarily close" all businesses "intended 
to facilitate anonymous, high-volume, high-risk sexual 
behavior. Hl 

Dritz: Which is political jargon for, "Close the baths." 
Hughes: Yes, exactly. 

Dritz: That was part of the battle going on. That was City Hall pushing, 
and the mayor also was of the same mind. You see, supervisors 
were elected at large, but Harry Britt was considered the 
representative spokesman for the gay community particularly. But 
the gay community was splintered, too. There were those that 
supported him completely, and there were those that hated his guts 



folder: 10-10-84 Declarations in Support, vol. 1. 

See also, "Doctors side with city in suit." San Francisco 
Examiner, October 12, 1984. (GLHS, AIDS clipping file, folder: 
Bathhouses - gay . ) 



*Randy Shilts. "SF planning to close gay baths. 
Chronicle, March 30, 1984, p. Al. 



San Francisco 



93 



and felt that he was a traitor because he was supporting City Hall 
to close the baths. So he had a big problem there, but he was a 
responsible man, and from our point of view he did a good job for 
the health and the welfare of the city and the gay community. 

Hughes: Did Silvennan lose his job as health director because of the 
bathhouse issue? 

Dritz: That was a very, very big factor. If there were others, I'm not 
aware of them. No health director at that time, at that place, 
could have survived that. It was a can of worms. It was huge-- 
nobody could have survived that. There was no way he could win. 
I think I saw him losing weight during that time. He was grey- 
haired anyhow, but if he hadn't been, his hair would have turned. 
I'm not being funny. It was a very traumatic time. I was losing 
weight then. We were all working like dogs, and aggravated and 
frustrated. Incidentally, he wasn't fired. He resigned when City 
Hall appointed a health department commission to set policy for 
health matters in San Francisco at about that time. Practicing 
public health and preventive medicine by committee or commission 
is not for San Francisco. 



The Continuing Problem of AIDS Etiology 



Dritz: But it was not only that. From the scientific aspect, we were 
going crazy. For instance, you had a question, "Is AIDS an 
infectious disease?" You finally assured yourself that you were 
pretty sure this was an infectious disease. You had clues: one, 
two, and three, that all pointed to an infectious agent. So we 
answered the question at least tentatively: it's infectious. 

Now, which of these clues was the most likely to lead us to 
the cause of the infection? Could it be a herpes virus, such as 
cytomegalovirus which causes blindness and herpes encephalitis in 
gay men? After all, a number of gay men had developed overt AIDS 
who maybe six months before had had very severe herpes zoster, 
which is caused by the varicella zoster virus which is also a 
herpes virus. 

On the other hand, if it was cytomegalovirus, it was rampant 
in the gay community- -genital herpes --but it was just as rampant 
in the heterosexual community. Now, if it was causing AIDS in the 
gays, why didn't it cause AIDS in the straight population, too? 

Well, we spent some time looking at that, and in the 
meantime, we didn't have people to look at possibility C or 



94 



possibility A. And then there were the other possibilities: is 
it blood transmitted, or is it just caused by repeated infections 
which diminish the immune response to below a critical level? And 
if that is so, then we'd have to go back to all these AIDS 
patients and find out how many other diseases they had had 
previously. 

Hughes: What a job! 

Dritz: Yes. And we couldn't spread ourselves that thin. Detective 

Hercule Poirot has clues one, two, and three, and he puts them all 
together and he has the answer. Well, this was a whodunit too, 
but we had the problem first to decide which clue to follow up. 
Which one would be the most effective, the most efficient? 

Hughes: What difference would it have made if the questionnaire had been 
processed faster by the CDC? 

Dritz: It would have helped. We spent a lot of time tracking down amyl 
nitrite. I sent Carlos Rendon, my epidemiology assistant, into 
the Jaguar Bookstore or the Ambush, and I think even the Mine 
Shaft, to buy amyl nitrite "poppers" that the gays were using to 
give themselves a sexual rush. He brought them back to us and we 
sent them down to CDC in Atlanta, and they analyzed them. They 
came up with amyl nitrite as the active ingredient. 

Well, if AIDS is an infectious disease and amyl nitrite is a 
toxin, it wouldn't cause the infection, but could it be a 
cof actor, or could it be activating an infectious agent? So we 
spent time investigating amyl nitrite. Finally, two years later 
when the CDC's computer analysis report came out, it said, "Forget 
it, it's not amyl nitrite." But we had lost time and effort 
looking at that possibility. 



The Effects of Insufficient Funding 



Dritz: So not only that, but if we had had more money, we could have had 
other people looking at other things at the same time. But it 
wasn't coming down from the feds and the Reagan administration. 
It wasn't coming down from the Deukmej ian administration. Even 
now if it had, we might be much closer to a possible effective 
treatment for the active cases. We might be closer to a vaccine 
to prevent new cases. 

There was homophobia at the top levels of the government, 
[pounds table] There's blood on their hands. I have to say that. 



95 



Don't let me edit that out of the transcript. I feel that very 
strongly. By withholding the money, people were dying here sooner 
or in greater numbers than they need have done. The epidemic was 
exploding. We already knew that it was exploding in Africa, and 
we could expect it would happen here. And we were already seeing 
heterosexual cases. 

Hughes: Well, it wasn't CDC-- 

Dritz: It wasn't their fault. It was top levels of government. 



Testinjz Stored Hepatitis B Blood for HIV Antibody 



Hughes: Knowing now about the long incubation period for AIDS, is it 
possible that even in 1981 there were already too many people 
infected to stop the epidemic? 

Dritz: Well, we went back to the CDC freezers for the hepatitis B trials 
bloods. The first bloods had been drawn in 1978, and when they 
were later tested for HIV antibody, they already had a 4 percent 
positive antibody rate. When they tested the bloods drawn in 1980 
and '81, I think they had 15, 20 percent positive. By the time 
they got to '85, '86, they were up to the 60, 70 percent infection 
rate. So the infection rate was not that high way back then in 
'78, and if we had been able to learn that this was a virus and 
there was a test for this, we might have been able to do something 
about it sooner. Or we could have run into the civil rights 
issue. We wouldn't have cured it; we wouldn't have prevented it; 
it's too complex a problem. But I think we'd be closer to the 
answer now, or we might already have solved part of it. As it is, 
even with all those delays, the average survival rate now from 
time of AIDS disease diagnosis to death is about eighteen months, 
where a few years ago it was only twelve months. 

But we would have been closer to it, and maybe some would 
still be alive now, and alive in a year or two or three when we 
hope to have the cure for AIDS, or at least a maintenance regime, 
as for diabetes. That's why I say, people died because the money 
didn't come through. And it didn't come through for a variety of 
reasons, some political and some "moral." I feel strongly about 
that. I'm not a red-hot liberal. As a matter of fact, year by 
year as I get older, I become more conservative. But as a doctor, 
I have to say that there was fault, for whatever motive moved it. 



96 



Dritz: It wasn't until I retired and I was replaced by a competent 

epidemiologist [Dean Echenberg] that he screamed loud enough to 
get a Dictaphone --"What kind of an office is this?" When I asked 
for a little index card case, I ended up using an old shoebox 
because my chief said, "We haven't got any money." 

Every budget time, you asked for as much as you thought you 
could get, and then you were told by City Hall, "Across the board, 
10 percent cut, everything." Well, you couldn't do it across the 
board. So we tried to figure out how we could get a 10 percent 
cut overall, knowing that we were cutting below what we needed. 
But come July, we'd go for a supplementary budget. That was how 
it worked. At the end of the year, if there were two or three 
dollars left in any one of the line item budgets, the chief would 
say, "What do you want to buy? If we don't use it up now, they 
won't give us that much next year." Which is how a lot of 
organizations work. But here we were screaming for money. 

Hughes: Screaming at the state level as well as the federal? 

Dritz: We were screaming at City Hall. It was their problem to scream to 
the state and the federal governments. But we were screaming to 
CDC, and they themselves weren't getting enough. Don Francis told 
one of the men in CDC who passed it on to me --this is hearsay- - 
that he couldn't get enough money to fix the handle on his 
laboratory door, which he thought might be a source of cross - 
contamination for his staff. 1 I think he finally got it fixed 
himself. That would have been in character. 

There just wasn't money. As I said, CDC had to share the 
Public Health Service's money with NIAID and the other NIH 
institutes. If CDC got more money, the institutes would have 
their budgets cut. They all needed the money, and it wasn't 
coming down from above because it was being shot up into the air. 
I think I am painting myself really red like a wild-eyed bomb- 
thrower. I am not. I'm a very, very nice Democrat. 



The Impact of Discovering the AIDS Virus 



Hughes: How closely had you been following the work in retrovirology? 

Dritz: Well, our office didn't do viral research, but we were aware of 

what was going on, particularly through the work of Jay Levy, who 



J Francis mentions this episode in his oral history in this series. 



97 



is the virologist at UCSF. He kept us up to date; we met at 
intervals . He eventually isolated a virus which turned out to be 
HIV, but by that time, [Luc] Montagnier and his group at the 
Pasteur Institute had isolated in a handful of their patients what 
they called the cause of AIDS. It wasn't recognized by the 
American establishment in Washington. 

Hughes: Why was that? 

Dritz: Because [Robert] Gallo was working on it at NIH. A year later he 
announced that he had it from a bunch of his patients . And then 
the big battle really took off, because Montagnier 's and Gallo 's 
viruses seemed to be the same. The question is still unsettled, 
although the scientists hold very "polite" meetings to solve the 
dispute. Gallo is appealing a reprimand now, I think, but I don't 
know directly. 1 

The crux of it is the honor of having isolated the virus of 
the greatest medical mystery of the century. There will be a 
Nobel Prize, and it's worth well over a million dollars now. 

Hughes: There was also the more immediate financial gain from the test for 
the AIDS antibody. 

Dritz: Yes, there was the antibody test. The commercial people are going 
to be paying a royalty to the government and to some of the 
universities, which now are also looking to the possibility that 
any portion that they or their researchers may have had in 
promoting the discovery of the AIDS antibody test should give them 
a proportionate amount of the royalty. 

There are unsavory ramifications to the idealism in medicine 
and science. Too many people think of fame and money. Of course, 
I'd like fame and money, too, but within the limitations of what's 
right and what's not acceptable. 

Once we had the virus and the test, work on the problem 
became primarily a job for the lab researchers and the clinicians 
and the hospitals to find treatment and a vaccine and to test out 
medications , which Don Abrams and his group at the County 
Community Consortium in San Francisco are doing very, very 
effectively. 

Hughes: In the early days of the epidemic, as you well know, the approach 
was epidemiological and multi-factorial . Some argue that after 



1 See: Joseph Palca. "'Verdicts' are in on the Gallo probe." Science 
1992, 256:735-738 (May 8, 1992). 



98 



the discovery of the virus, epidemiology became less important in 
defining the disease. 1 

Dritz: No, it didn't. We had the first step of the puzzle solved: we 

knew what caused it, and we had a test for the antibody. We still 
have the problems of what groups were more at risk for AIDS , why 
were we getting more cases among IV-drug users, why were we 
getting somewhat fewer cases among the older gays? 

[tape interruption] 

The problem of diminishing the opportunities for transmission 
hadn't gone away yet. Even with the baths closed, men were still 
having a lot of contacts at other places, in their sex clubs and 
the back rooms of the bars and so on. But we had a test now, so 
we could offer them the opportunity to find out if they had been 
infected. If two men wanted to become monogamous partners, and 
that became a movement for a while, then they could test 
themselves and see if they were both clear. 

On the other hand, many of them were afraid to be tested, 
because they didn't want to know that they were infected. If they 
were found to be positive, then perhaps their whole way of life, 
their associations, their work, their insurance, their place of 
living, everything, would change. Their lovers, their friends 
would drop them completely. So the answer to the cause of AIDS 
and the test for the virus became intricately entangled with the 
problem of confidentiality. Before we had the AIDS antibody test, 
a man presumed gay was outside the pale of general society. Now, 
a man known to be infected was not Just outside, he no longer 
existed. He was thrown out of the gay community and the world- - 
his world. 

So the question became, how do we get men to come in to be 
tested? How do we assure them that they won't suffer if they're 
found positive? How do we assure them that they'll be able to 
have access to care if they are positive and they haven't got any 
money for it? This again became epidemiology, because we had to 
search the neighborhoods --not on a one-to-one basis, but by word 
of mouth- -get word out that we wanted to offer them a chance to 
prolong their lives, if they were found positive, by getting 
medical care. We also wanted to assure them that by anonymous 



J For example, see G. M. Oppenheimer. In the eye of the storm: The 

epidemiological construction of AIDS. In: E. Fee, D. M. Fox, eds. AIDS: 

The Burdens of History. Berkeley: University of California Press, 1988, 
pp. 267-300. 



99 



testing they wouldn't pay for it with the loss of insurance and 
their livelihood and everything else. 

There again, our rapport with the community helped a lot. 
But we still had the resistance of the red-hot gays who screamed, 
"Confidentiality! Civil rights! It's our right to live the way 
we want to!" And it is their right to live the way they want to, 
unless they kill somebody doing so. Testing positive is still a 
sentence of death- -maybe not as soon as in two or three months of 
diagnosis as it was at the beginning, but still eventually they 
will die of this unless we find a cure or a maintenance regime 
soon. 



Broadening the Definition of AIDS 



Hughes: Did the diagnostic test affect the case definition of AIDS, which 
heretofore had been based on the opportunistic diseases that 
developed as a result of the immune suppression? Was it enough to 
say that a person had the virus, and therefore that defined the 
disease? 

Dritz: No, that wasn't the thing. The definition of the disease was 

changed several times by CDC on the basis of complications that 
develop in patients with AIDS. A person who is positive and has 
no symptoms is infected; he's a symptomless AIDS statistic. With 
the first definite symptoms, he becomes by CDC's definition an 
active AIDS case. But it didn't depend so much on whether we had 
a diagnosis that he was antibody -positive, and therefore infected, 
but that each new complication- -cytomegalovirus, Burkitt's 
lymphoma, lymphoma of the brain, Hycobacterium avium 
intracellulare, cryptosporidiosis, cryptococcosis, even some cases 
of coccidioidomycosis, a whole bunch of fungal infections, herpes 
zoster, candidiasis- -all of these slowly were added, in a 
different order than I've given to you, to the definition of AIDS, 
making more persons eligible for AIDS financial support from one 
government agency or another. 

CDC at first defined an AIDS case as, "A person with no known 
predisposition for immunosuppression, " from cancer therapy or 
something, "who is younger than sixty years, a male, with Kaposi's 
sarcoma or Pneumocvstis pneumonia." 1 So at first it was only 



1 Centers for Disease Control. Update on acquired immune deficiency 
syndrome (AIDS) - -United States. Morbidity and Mortality Weekly Report 
1982, 31:507-514. 



100 



sarcoma or Pneuntocystis pneumonia." 1 So at first it was only 
those two conditions. And then I got them to add Burkitt's 
lymphoma; others got them to add cytomegalovlrus , toxoplasmosis .* 
The CDC was slow In changing the definition, because every time 
they changed it, they had to go back and rework the computer data. 
Our data from San Francisco went into the computer also, without 
personal identifiers. For confidentiality control, the health 
department shredded my notebooks . 

The latest definition by CDC has increased the numbers of 
persons recognized as cases and therefore eligible for payment for 
their treatment If they have no other resource. 3 The costs of 
management of this disease are just exploding. 

A person who's positive may go two or three years without any 
symptoms, and so he's only antibody positive and is not 
reportable, because of confidentiality. But the person who is 
positive and has symptoms is diagnosed as a case of AIDS. 



Health Care Workers and the Risk of AIDS 



Hughes: Do you think physicians have an obligation to care for AIDS 
patients? 

Dritz: There's absolutely no question about that. A physician has an 
obligation to care for any patient who requests his help. It's 
the Hippocratic Oath; you don't turn anyone down. If you don't 
care for him, you have to have a good reason, and you have to give 
him a reference to someone who can care. You Just don't abandon a 
patient. On the other hand, a physician can hardly be severely 
criticized for being cautious about exposing himself to an 
infection or hazard which might be dangerous to his own health or 
make him liable to transmit something dangerous to his other 



1 Centers for Disease Control. Update on acquired immune deficiency 
syndrome (AIDS) - -United States. Morbidity and Mortality Weekly Report 
1982, 31:507-514. 

2 Centers for Disease Control. Revision of the case definition of 
acquired immunodeficiency syndrome for national reporting- -United States, 
Morbidity and Mortality Weekly Report 1985, 34:373-375. 

3 See: 1993 revised classification system for HIV infection and 
expanded surveillance case definition for AIDS among adolescents and 
adults. Morbidity and Mortality Weekly Report 1993, 269:460. 



101 



make him liable to transmit something dangerous to his other 
patients. He has to take proper precautions within the limits of 
what knowledge is available to him. 

In the case of AIDS, there were physicians who were worried 
if a patient coughed in their face and the droplets got to the 
mucous membrane of the eyes , because that would be presumably a 
way to transmit "body fluids." Well, with experience, we know now 
that probably doesn't happen. But we can never say 100 percent. 

Hughes: Were you ever concerned personally? 

Dritz: When I was a very young pediatrician, I took care of smallpox 

cases; I took care of chicken pox; I took care of tuberculosis; I 
took care of scarlet fever. These diseases were transmissible, 
and we didn't have penicillin yet. At that time, we just had the 
sulfa drugs, which maybe would and maybe wouldn't protect us from 
one thing or another. We didn't have the vaccines. For scarlet 
fever all we had was the Dick test to see if we were immune; we 
had no treatment for it, except sulfa drugs and supportive 
treatment. So, you took your risks. 

Hughes: So dealing with an untreatable infectious disease was nothing 
particularly new to you. 

Dritz: This was the same thing. We didn't know for sure how AIDS was 
transmitted. I made it a point to shake hands with patients, 
because some of them used to say, "My friends don't even want to 
shake hands with me. They put their hands behind their backs. 
They used to come in, they put their arm around your shoulder and 
hug you. Now they don't. I feel like I'm outside the world; I'm 
encased in something." I made it a point to have them sit at the 
desk and talk a long time. One or two of them would start to cry; 
I'd give them my Kleenex. Then they'd stick it in their pocket; 
they didn't want to stick it in my wastebasket. I told them, 
"Forget about it; it's all right." You took your chances. You 
were a doctor. 

Hughes: Well, AIDS wasn't the same as the other infectious diseases 

because of its 100 percent fatality, but I guess in the very early 
days, you didn't realize that. 

Dritz: No. But we did know scarlet fever could give you a damaged heart, 
which would kill you in time. We did know that diphtheria could 
choke you to death with membranes in your throat. There wasn't 
the 100 percent fatality of AIDS, and we knew at least what was 
causing them; we just didn't have very good treatment for them. 
And we knew how they were transmitted. We didn't have treatment 



102 



for AIDS, and we didn't know what was causing it, but we knew that 
there was a risk. 

The other doctors in the health department clinics and 
hospitals treated AIDS patients the same as I did. When we 
started the anonymous AIDS testing program, the doctors there were 
drawing bloods on the patients. This was a needle-stick risk, and 
yet they did their job. In the hospital on Ward 5B [the AIDS ward 
at San Francisco General Hospital], the nurses and the 
phlebotomists were drawing bloods on the patients, with needles, 
and they were at risk. We learned later that some of them did 
become positive a very, very small percentage, but some did. But 
you did your job. 

Some doctors and nurses refused to take care of AIDS 
patients. Some aides didn't have a great deal of knowledge of 
transmissible disease and were afraid to walk into the patient's 
room with a tray of food. They'd leave it on the floor outside. 
We could understand why they felt that way, although we didn't 
feel it was the best thing for everyone concerned. But most of us 
took our risks. 

Hughes: When was the height of the hysteria, would you say? 

Dritz: Late '81, early '82. It was still simmering through '82. By '83, 
we were beginning to see that it was an infectious disease, but 
the agent had to get into your bloodstream. By November of '82 we 
had Ammann's baby diagnosed with AIDS as a blood- transmitted 
disease. So by '83 we were able to say pretty surely, "It won't 
go through a handshake, and it won't get to you from the 
telephone. But if you're punctured with a needle that's been in 
the skin of a patient who has AIDS, you might get it." And we 
didn't know then that a person who's infected with AIDS but not 
yet sick is already infectious and dangerous by needle stick. So 
the situation was really very, very complex and vague. 

Once, one of the news anchors was doing a remote newscast 
from my house and asked me, "Do you guarantee that we'll not get 
AIDS through the air?" I had to say, "We can't guarantee 
anything." But in medicine, you don't guarantee anything. 



Findine Treatment for AIDS 



Hughes: Americans increasingly expect science or medicine or both to "fix" 
disease. We're not used to having unsolved problems. What do you 



103 



think is the impact of the fact that so far we haven't 
AIDS? 



fixed" 



Dritz: Well, I think your statement is not completely accurate. 

Americans did expect doctors to be able to "fix" disease, but now, 
what you hear from too many people is, "Doctors are incompetent," 
or "Doctors are crooks," or "Doctors are looking for big money," 
or "Doctors won't take a night call." So, with that mixed view of 
doctors now, it's no wonder that they are not surprised that we 
haven't "fixed" AIDS yet. On the other hand, the public doesn't 
notice the very slow, slow, step-by-step progress we're making, 
which we see in the medical journals, which come out maybe four, 
five, six months after the fact. 

Americans, especially the younger generation, want instant 
gratification. You've got the disease today; you have to have the 
cure, the magic bullet, tomorrow. It doesn't work that way, not 
with something this complex. Jim Curran from CDC said a long time 
ago that the cure would be found eventually, but it was going to 
take a long time. There are a lot of steps to take. There are a 
lot of questions to ask, and a lot of other questions that rise 
from each answer. 

Hughes: What was his basis for saying that? 

Dritz: He was saying that from his knowledge of past history of 

conquering diseases. It was much slower in the past because we 
didn't have instant communication between the different medical 
centers and so on. Koch with tuberculosis worked a number of 
years before he published a paper. Pasteur worked a long, long 
time and wasn't even believed for a long period. We started with 
a disease we didn't know anything about, and in ten years we know 
what is causing it, we know where it is, we can pull its genetic 
patterns apart, we have a test for it, and we're on the road to 
preventing it with a vaccine. 



Accelerated Approval of AIDS Drugs 



Dritz: Drug approval could go faster, except you have to test carefully, 
because each thing you use might have a bad side effect or cross 
reaction with other medications, worse than the benefit. The Food 
and Drug Administration is right in being cautious, although many 
times it's been too cautious and kept us from using medications 
which might have done some good. We've had to twist arms and 
scream to get them to loosen things up. 



104 



Hughes: Which they have by speeding up the approval of drugs for AIDS and 
other life -threatening diseases. 1 

Dritz: Well, the establishment hasn't screamed as much as activist groups 
in the gay community, like the ACTUP [AIDS Coalition to Unleash 
Power] group have. 

Hughes: What about the three drugs that are now on the market, AZT, ddl , 
and ddC? 

Dritz: We've known about them for a year or two already. 
Hughes: Their approval wasn't speeded up? 

Dritz: They were approved faster than they would have been if they hadn't 
been pushed politically. If we had had better support from the 
top of the government, they would have been approved faster. We 
have the president; we have the cabinet; we have the secretary of 
health, Louis Sullivan, and he does the bidding of the president, 
because he's appointed by the president. I'm not blaming him for 
anything. I'm not blaming the president. I'm just saying, 
whatever their motives were, even the best, they have caused 
delays which result in the loss of life, which might have been 
avoided or at least delayed. 



AIDS in Women 



Hughes: From early in the epidemic, women have been known to be 

susceptible to AIDS, and yet AIDS in women has not been a great 
area of investigation or even education. 

Dritz: Well, it hasn't been from the very first, but gradually we found 
that women were susceptible to AIDS, particularly those who were 
using intravenous drugs. However, it was the heterosexual 
transmission to women from high-risk men that caused the shift of 
attention to women. 



1 See: H. Edgar and D. J. Rothman. New rules for new drugs: The 
challenges of AIDS to the regulatory process. In: D. Nelkin, D. P. 
Willis, and S. V. Parris, eds . A Disease of Society: Cultural and 
Institutional Responses to AIDS, pp. 84-115. 



105 



Dritz: Connie Wofsy has been concentrating on AIDS in women, and she's 

been doing a fantastic job and published a number of papers. She 
should speak for herself on that. 1 So I won't comment too much, 
except that the press coverage was spotty. Recently the women's 
movement has pointed out that women are at risk from many, many 
sources- -battery, sexual assault and that women in danger for any 
reason should be recognized and helped and publicized. But I 
don't think that the press has made a particular point of women as 
victims of AIDS, except as victims of the general milieu which 
permits women to be in hazard because of activities of men around 
them. 



Retirement 



Hughes: You retired from the health department on April 24, 1984. Is 
there a story? 

Dritz: Not really. I had planned to retire a month or two earlier. You 
see, when Montagnier and then Gallo announced that they had found 
the virus, and later a test for the antibody was developed, more 
or less that answered our question, "What's causing this epidemic? 
Where's it coming from? How's it transmitted? Who has it? How 
can we keep patients from giving it to other people?" We could 
test for it; we could identify those who were at risk and who 
could put other people at risk. The basic questions from my part 
of it, epidemiology, the detective job, were more or less 
answered. 

Now, a lot of epidemiological questions still remain. Moss 
and his group, using my data, were able to see how long patients 
survived with various complications of the AIDS infection. 2 Which 
areas now were developing AIDS more rapidly than other areas? 
Which populations are developing it more rapidly than others? But 
the basic question, "What is this, and where is it, and how do we 
attack it?" we had answered. 

And I was already past retirement age. I don't subscribe to 
the term "burnout" but it had been a hectic time. Our office was 
a pressure cooker, with everything coming through except TB and 
VD. But with AIDS, there was also the radio and the TV and the 
newspaper people interrupting what we were trying to do. We were 



1 See the oral history in this series with Constance B. Wofsy, M.D. 
2 See the oral history in this series with Andrew R. Moss, Ph.D. 



106 



talking to different communities, trying to assure different 
members of the health profession that they were not at risk, and 
traveling to northern California and southern California and to 
Atlanta and New York, all over the country, on this AIDS problem. 
I was tired. And there were a number of things yet that I wanted 
to do with my life that I never had had time to do. So it was 
time to quit. 

My colleagues were very, very nice about it. We're still all 
good friends. I get back to the health department for various 
clinics and grand rounds and such. My medical license is in 
order. I could go back to practice any time I wanted to. I 
continue with the CME, Continuing Medical Education. But I prefer 
not to be earning my keep right now. 

Hughes: Is there anything on this subject that you want to add? 

Dritz: Only that you have been a marvelous interviewer, that without your 
questions and guidance I would probably have been all over the 
lot, which I probably was anyhow. 

Hughes: Thank you. 



Transcribed and Final Typed by Shannon Page 



Regional Oral History Office University of California 

The Bancroft Library Berkeley, California 



The San Francisco AIDS Oral History Series 



THE AIDS EPIDEMIC IN SAN FRANCISCO: THE MEDICAL RESPONSE, 1981-1984 

Volume I 



Mervyn F. Silverman, M.D, M.P.H. 
PUBLIC HEALTH DIRECTOR: THE BATHHOUSE CRISIS, 1983-1984 



Interviews Conducted by 

Sally Smith Hughes 

in 1993 



Copyright 1995 by The Regents of the University of California 




Mervyn F. Silverman, M.D., M.P.H., 1983 



INTERVIEW HISTORY--by Sally Smith Hughes 



Dr. Silverman was interviewed because he was director of the San 
Francisco Department of Public Health from 1977 to 1985, precisely the 
years in which the AIDS epidemic was building and breaking. 
Appropriately, his oral history is bound with that of Dr. Selma K. Dritz, 
the only other voice representing the health department in this series. 

As director, he was official coordinator of all health-related 
activities in the City and County of San Francisco, some of which he 
describes in the first interview. "There was really no aspect of health 
care [in San Francisco]," he stated, "that wasn't somehow touched by the 
health department." As a result of his myriad professional 
responsibilities, the AIDS epidemic was at first only one of his many 
concerns . 

By early 1983, his other official duties began to pale in comparison 
to those engendered by the expanding epidemic which was devastating the 
city's gay community and raising complex medical and political problems 
in its wake. The oral history tells, among other things, of establishing 
AIDS education programs, the department's AIDS Activity Office, and 
anonymous sites for AIDS testing. 

However, it is Silverman 1 s views on the so-called "bathhouse crisis" 
of 1983 and 198A which are the oral history's major focus. The question 
was, should he close the city baths, heavily frequented by gay men, 
because some saw them as locations of indiscriminate sex and hence as 
sites of AIDS transmission? He was battered from all sides by the 
political factions active in the epidemic in his determination to listen 
to every viewpoint. Sensitive to the political agenda of the gay 
community, he knew it saw the bathhouses as symbols of newly won gay 
liberation. 1 In fact, the community's considerable size and high degree 
of political organization and social cohesion largely stemmed from this 
achievement. Silverman was sympathetic to the view that bathhouse 
closure would be seen as a step backward and a dangerous affront to the 
gay movement. He determined that closure would be counterproductive 
unless he had the support of the gay community. But the community itself 
was fractured into opposing political groups which could not reach 
consensus. Without consensus, Silverman at first refused to mandate 
closure, hoping that educational programs would stem the rising tide of 
infection. 

While sensitive to the views of the gay community, Silverman at the 
same time was accountable for the city's health and welfare. Mayor 



1 See, for example: Press Statement of Civil Rights and Lesbian and 
Gay Community Organizations, October 10, 1984. (Dean Echenberg papers, San 
Francisco Department of Public Health, Bureau of Epidemiology and 
Communicable Disease Control, drawer: bathhouses, folder: sex 
clubs /bathhouse. Hereafter: Echenberg papers .) 



Dianne Feinstein, some physician groups, and a few gay activists, 
including the journalist and author Randy Shilts, pressed for closure. 
But Silverman's medical advisory committee, composed of representatives 
of local medical institutions and the community, failed to reach 
consensus on the issue. 

Silverman remembers a turning point, probably in August of 198A, 
after one of the meetings of his committee: 

I remember walking out of the meeting and saying, I've met with 
the community enough; I've met with the advisors enough; I'm 
just going to make the decision and I'm going to follow 
through. And that night I said, I'm going to close them. 1 

On October 9, invoking emergency powers, he issued an order to close 
the baths. As he stated for the press: 

Today I have ordered the closure of 14 commercial 
establishments which promote and profit from the spread of 
AIDS--a sexually transmitted fatal disease. These businesses 
have been inspected on a number of occasions, and demonstrate a 
blatant disregard for the health of their patrons and of the 

community Make no mistake about it. These 14 

establishments are not fostering gay liberation. They are 
fostering disease and death. 2 

The oral history describes further legal actions yet to come, but 
the public crisis was essentially over. On a personal level, Silverman's 
troubles were still unfolding. In December 1984, he resigned as health 
director, forced out by a political system looking for a victim. 

Yet Silverman's involvement in the epidemic was far from ended. He 
spoke of his subsequent role as director of the AIDS Health Services 
Program of the Robert Wood Johnson Foundation (1986-1992), and his 
current positions as president and national spokesman ( 1986-present) for 
AmFAR, the American Foundation for AIDS Research. 3 



The Oral History Process 



1 p. 156. 

2 Press statement of Dr. Mervyn F. Silverman, October 9, 1984. 
(Echenberg papers, folder: sex clubs /bathhouse. ) 

3 This portion of the interview recorded on July 6, 1993 is outside 
the project's time frame and for this reason, as well as funding 
limitations, was not immediately transcribed. The tapes are on deposit 
at The Bancroft Library. 



Three interviews were recorded with Dr. Silverman between March and 
July, 1993 at his attractive Victorian home in San Francisco's Upper 
Haight-Ashbury District. The interviews were sandwiched into visits home 
from AmFAR's New York and Los Angeles offices. Although Dr. Silverman 
appeared relaxed and friendly, the frequent telephone interruptions 
indicated the hectic pace of his life. (The last interview was conducted 
with one hour's notice.) Nonetheless, he spoke willingly of the 
stressful San Francisco period of his career, obviously concerned to 
explain his consensus approach to bathhouse closure. 

The interview transcripts were edited, rearranged for better 
chronology, and sent to Dr. Silverman who edited them lightly, suggested 
further rearrangements, and then went over them a second time. The 
result conveys his reactions to an exceedingly complicated and 
f ascinatingepisode in AIDS history and in the process reveals a man 
sensitive to the diverse and contentious factions active in the early 
years of the San Francisco epidemic. 



Sally Smith Hughes 
Interviewer/Project Director 

January 1995 

Regional Oral History Office 

The Bancroft Library 

University of California, Berkeley 



Regional Oral History Office 
Room 486 The Bancroft Library 



University of California 
Berkeley, California 94720 



BIOGRAPHICAL INFORMATION 
(Please write clearly. Use black ink.) 



Your full name 




Date of birth 



Father's full name 

Occupation_ 
Mother's full name 

Occupation 
Your spouse 



j&&Wsi 



Birthplace 



Your children 



Where did you grow up? 

Present community 

Education 



Occupation(s) 



Areas of expertise 




>^fc 











Other interests or activities 




Organizations in which you are active 



*^ 



107 



I EDUCATION AND CAREER 
[Interview 1: March 23, 1993] 

Education and Early Career 



Hughes: Dr. Silvennan, could you give me a brief summary of your 
education and early career? 

Silvennan: Yes, I went to Washington and Lee University [1956-1960] for my 
undergraduate work, and then to Tulane Medical School [1960- 
1964] for my medical training. Then after interning at Los 
Angeles County General Hospital, I went with the Peace Corps in 
Thailand as a Peace Corps physician. Then I became regional 
medical director for Southeast Asia and the Pacific [1967-1968] 
for the Peace Corps. [tape interruption] 

I then went back to school to get a master's degree in 
public health at Harvard [University] [1969], then went with 
the Food and Drug Administration as special assistant to the 
commissioner [1969-1970], and then director of the Office of 
Consumer Affairs [1970-1972]. I really wanted to get closer to 
the people, because from Washington it is very difficult to see 
any impact on people. So I became director of health in 
Wichita, Kansas [1972-1977], and also ultimately medical 
director of Planned Parenthood for Kansas [1976-1977]. 

Then in 1977- -I guess it was it was as early as '76- -I saw 
an ad for a job as director of health in San Francisco and 
applied, and ultimately was appointed, to start in May of 1977, 
a job which I held until January of 1985. 



*## This symbol indicates that a tape or tape segment has begun or ended. 
A guide to the tapes follows the transcript. 



108 



Interest in Public Health 



Hughes: 



Silverman: 



Hughes : 



Sllverman: 



Why public health? That started with the M.P.H. [Master of 
Public Health] degree [1969]? 

Well, I guess it started even a little before that, although I 
probably didn't know it at the time. When I was in medical 
school, between my sophomore and junior year I worked as a 
research assistant in South America. I think that planted the 
seed- -the idea of doing some public health-type work. And then 
Peace Corps really solidified my interest. I realized after 
Peace Corps, even though I was taking care of all the 
volunteers we had in Thailand, that I could never practice 
medicine the way I did there. I was with them when they were 
healthy, and so when they were sick, I really knew them. I 
used to be "Merv" when they were well and "Dr. Silverman " when 
they were sick, and that was a very interesting relationship. 

I realized I could never have something like that in the 
States, and that a private practice would be too confining, and 
that the real way of dealing with diseases was to prevent them 
rather than trying to treat them after the fact. So that's 
when I went to Harvard and also did what was really a residency 
in preventive medicine, and then got my boards [1970] in the 
specialty of preventive medicine. 

With the idea of becoming a public health director? 

I'm not sure that I really thought about what exactly I would 
do. I just found out after being in Washington and the federal 
government, and though I was born and raised in Washington 
D.C., I realized that it was too far away from really having an 
impact on people. I thought local health was really where I 
should be, found that to be the thing I enjoyed most, and 
actually spent a total of almost thirteen years [1972-1985] in 
local health in Wichita and San Francisco. 

When I went to medical school, I didn't even think about 
public health as an option. In those days, people in public 
health were either people from private practice who were 
retiring, or people in the military, or people who just 
couldn't make it in private practice. So public health wasn't 
held in the highest esteem. 

But what happened with Peace Corps is a lot of young 
physicians, who probably had no thought of going into public 
health, had their heads turned around during and after the 
Peace Corps experience. So there was a whole cadre of young, 



109 



energetic, eager individuals going into public health, and I 
think that sort of rejuvenated the whole system. 

Hughes : Did the experience in Kansas tie in with what you were going to 
be doing in San Francisco? 

Silverman: In absolutely no way, shape, or form! [laughter] There were 
no pressure groups. I think Native Americans, the Indians, 
were a little bit vocal, but you could ignore them and not have 
to worry about it. 



Director. San Francisco Department of Public Health. 1977-1986 



Comparison with the Department of Public Health in Kansas 



Silverman: Then coming to San Francisco, where on every corner there is 

another interest group based on race, religion, ethnicity, age, 
disability, sexual orientation, medical society, or hospital 
affiliation, you name it, was a real eye-opener, and so a real 
education for me. 

Hughes: Did you realize what you were getting into? 

Silverman: After I was appointed, I was sort of stunned, like the dog 

who's caught the car. What do you do with it now, after you've 
chased it? I really was very concerned that I had decided to 
do something that I might not have the ability to do, that 
maybe according to the Peter principle, I had reached my level 
of incompetence in Wichita, and what was I going to do here? 
So it was scary, but it was very exciting. 

Hughes: Scary mainly from the standpoint of the factions that had to be 
dealt with? 

Silverman: Yes. There Is a classic little postcard that shows Dorothy and 
Toto from The Wizard of Oz in a leather bar in San Francisco 
saying, "Toto, I don't think we're in Kansas any more." It was 
very clear to me that I wasn't in Kansas any more. 

I had in Kansas a department of around 100 people, and 
Just classic public health problems. I didn't have mental 
health; I had alcohol but no substance abuse; I didn't have any 
of the medical services, really. We had some clinics in the 
health department, and a budget I think of several million 
dollars. I don't remember. Then here I had a budget of 



110 



several hundred million dollars, and 5,000 employees. I used 
to say then- -I don't say now- -that we were involved in 
everything from bathhouses to brain surgery. Of course, I 
didn't realize that bathhouses were going to be a major part of 
my experience here. 

What makes the San Francisco Public Health Department so 
unique and I think so great compared with others around the 
country is that it is an umbrella agency that truly has 
everything, from emergency care- -the emergency medical 
services, ambulance services, a major trauma center in northern 
California- -to an acute care hospital, San Francisco General; 
Laguna Honda Hospital, for long-term care; and then mental 
health and drug abuse and alcohol- -just everything. There was 
really no aspect of health care that wasn't somehow touched by 
the health department. 

In Kansas, I would sometimes have to have my secretary or 
nurse stay on the phone all day going through the yellow pages, 
trying to find a physician who would take a public patient- -a 
patient on Medicaid, which here is Medi-Cal. Here, if the 
health department took a Medi-Cal patient, the medical society 
was upset, or sometimes the hospitals were upset. 



Relations with Other San Francisco Institutions 



Silverman: I became very actively involved in the medical society from day 
one. In fact, on my first day here, which was the second of 
May [1977], that night was a medical society meeting and I went 
to it, and was active throughout my tenure here. I realized 
that we had to work with these people, because they actually 
saw the health department as competition. 

Hughes: So there was a tension between the medical society and the 
health department? 

Silverman: Oh, yes. And there had been, but as I became an active member 
of the society, we worked very cooperatively. In fact, until 
this year when I didn't run, I've been elected as a delegate of 
the San Francisco Medical Society to the California Medical 
Association for the last dozen years. If there was a public 
health issue, the medical society would call me for my advice 
and usually they would follow it. I was on the Political 
Committee, looking at the political issues in the city, and 
state. The medical society and the health department worked 



Ill 



very, very closely during those years, 
should happen. 



Which is what I think 



Hughes: How was the relationship between the health department and the 
university? 

Silverman: Well, that was actually fairly good, because we were trying to 
get a new contract between the university and the city for San 
Francisco General Hospital. So although there were some 
tensions, I think it was very clear to myself and many of us 
that this was a very symbiotic relationship. The university 
really needed us, and we really needed the university. 

Now, there's always arguing about who got the better end 
of the deal, and I don't know that anyone really did. But we 
could not have run the hospital without the university, and I 
don't think the university could have had the kind of clinical 
experience without the hospital. 

Hughes: Were you immediately involved in that negotiation? 
Silverman: Yes, relatively soon after I arrived in 1977. 
Hughes: Did the terms remain what they had been? 

Silverman: We never arrived at a contract by the time I left in 1985. I 
assume one has been reached, but 1 haven't seen it. 

Hughes: Were there any other particular issues during the years in San 
Francisco right before the AIDS epidemic? 

Silverman: Well, there were many, many issues. I closed the emergency aid 
stations [1978], which was very controversial. There were 
emergency aid stations around the city that were giving very, 
very poor care, but it was something the city was used to. If 
you burned yourself, cut yourself, had a little problem, 
thought you maybe had some pressure in your chest or whatever, 
you'd go to these places. A lot of people went there who were 
on Kaiser [Permanente] but rather than going all the way across 
town, if they could get it done there, it would save them time 
and money, and mostly energy. 

They were poorly run, and I just couldn't see, with the 
number of hospitals and the number of emergency rooms, keeping 
these stations open. When I closed them, there was picketing, 
they put pictures of me up around the neighborhood, they 
followed me up to Sacramento when I was appointed to the 
advisory committee to assist the new state director of health 
[Beverly Meyers], and so that was one of my early tastes of San 






112 



Francisco politics. But by the time that was over, I was 
celebrating with them. They gave me a T-shirt, "I sat in 
Alemany for 43 days," and we actually ended up having a pretty 
good relationship. But it was a new experience. 



Threat to Remove the Health Department's Jurisdiction over 
San Francisco General Hospital 1 



Silverman: There was a situation at San Francisco General- -it may have 

been in the early years of the epidemic --where it was reported 
several people had died because of negligence. I had heard of 
only one case. The other two had not been made known to me by 
the administrator of the hospital. Probably one of my biggest 
problems is that I'm not as bastardly as I should be on certain 
occasions. The hospital lost accreditation. If I had fired 
the administrator, I'd have come out smelling like a rose. I 
could have said, he didn't keep me informed, blah blah blah-- 
gone. 

I wasn't aware of all the details at the time, and I 
didn't fire him. I figured, Let's see if we can work this out. 
I had a press conference. I've always felt, if I'm the head of 
the health department, I take responsibility. That probably 
wasn't totally smart. My successor was smart, and he had a 
person to share credit and blame. When the situation was bad, 
he put the person up who took the gaff, and when it was good, 
the health director got some of the credit. 

[Roger] Boas, the chief administrative officer, used me as 
the scapegoat. He was going to take the hospital away from me. 
Which was fought by a lot of people. 

Hughes: You mean take it out of your jurisdiction? 

Silverman: Exactly. And [Mayor Dianne] Feinstein went along with him. I 
was very upset. I was getting calls from mayor's staff saying, 
"Gee, we're really sorry about what's happening," and I was 
saying, "But I was so loyal to the mayor," and they laughed, to 
a person. "What are you talking about? Loyalty's a one-way 
street here. " 



section was moved from Interview 3 for better continuity. 



113 



Ultimately the hospital remained under the jurisdiction of 
the health director, but only after several flip-flops by Boas. 



Departmental Links vith the Gay Community 



Hughes: Well, talk now about the relationships between the health 

department and the gay community that pre-dated the epidemic. 

Silverman: Well, I was involved I guess somewhat peripherally with the gay 
community. They had asked me to participate and ride in the 
Gay Liberation Day parade, which I did. I always felt that the 
department should reflect the city in its makeup and in its 
services. Certainly the lesbian and gay community was and is a 
very important segment of the community. I had a lesbian/gay 
coordinating committee within the department to help sensitize 
the department to issues, and also to serve as a liaison when 
different issues were raised. So we were sort of ahead of the 
game in that sense. 

Hughes: Had you established that? 

Silverman: I think there may have been a committee before I came. I 

strengthened it, and had a full-time staff person dealing with 
it. I don't remember whether I started it. But certainly, it 
got more involved after I got there. 

Hughes: Was Pat Norman the committee head? 

Silverman: Yes, she was head of it at the time. In fact, I know she was 

when the AIDS epidemic started. Now, whether she had been head 
all the way from the beginning, I'm not sure, but I think so. 

Hughes: What sorts of things was she supposed to be dealing with? 

Silverman: It was to make sure that our clinics were sensitive to issues 
that related specifically to the lesbian and gay community, 
that we were responsive to the needs of the community. I can't 
remember how often the committee met; it didn't meet every 
month, I don't believe. If an issue came up from the 
community, that would come generally through that group to me. 

Hughes: Because of the committee, the department had links with key 
members in the gay community? 

Silverman: Yes, I did by virtue of becoming more actively involved. There 
were people that I knew in the gay community who wanted me 



114 



involved, so I was invited to their social affairs; I was in 
their parades. I would usually have my wife and kids ride in 
an old car or what have you, in the parades. So I just 
happened, both in my community here where I live and also the 
health department, to have friends, some of whom were members 
of the gay community. Maybe I spoke at one of the dinners of 
the Bay Area Physicians for Human Rights. I Just don't 
remember. I was active in those ways, just as I was with the 
black leadership forum and the Italian-American community out 
at Laguna Honda, and various other groups. 

Hughes: So the gay community was just another faction that you had ties 
with. 

Silverman: Yes. 



115 



II THE AIDS EPIDEMIC 



Becoming Aware of the Epidemic 



Hughes: Tell me when you first became aware of the epidemic? 

Silverman: Well, I remember the Morbidity and Mortality Weekly Report, 

MMWR, in June of 1981 that spoke about this strange situation 
of five white gay men. 1 

Hughes : You read the MMWR routinely? 

Silverman: Yes. This was an interesting medical oddity of some sort. It 
certainly didn't pique my curiosity to any great extent. 

Hughes: It didn't really register. 

Silverman: No, not any more so than many of the other things that were 
there. Then I think it probably came from Selma [Dritz] and 
others in the Division of Communicable Diseases [in the health 
department] that they were starting to see these cases in San 
Francisco. The numbers, though very small, obviously were 
increasing. 

Hughes: When did it hit you that the city had a real problem on its 
hands? 

Silverman: Oh, I think by the end of '81, we certainly had the sense that 
this was not something small. 

Hughes: Were there other reasons? 



ipneumocystis pneumonia- -Los Angeles. Morbidity and Mortality Weekly 
Report 1981, 30:250-252 (June 5, 1981). 



116 



Silverman: I think mainly the Increasing numbers. And the Ignorance that 
we had as to the etiology. We weren't sure If it was a toxin, 
whether It was bacterial, what it was. We had a sense about 
mode of spread. Everyone was talking about poppers. 
Especially related to KS [Kaposi's sarcoma). There was every 
kind of conspiracy theory. [tape interruption] 

I certainly knew we had an epidemic on our hands when we 
were planning Ward 5A. We hadn't planned any real model, but 
we kept growing to meet the needs . As more people needed to be 
screened, we wanted to take that burden off the clinic. So we 
set up a screening clinic. Well, when you're setting up 
screening clinics, and you have a clinic devoted specifically 
to AIDS, and you have an inpatient unit being prepared, you've 
got an epidemic. I mean, it's real. That was going on in '82. 

So if you ask me, did I ever believe we'd be where we are 
today, no. I don't think I envisioned a worldwide pandemic 
that is growing In the way in which it is. But we were very 
well aware at that time that we had a problem; we had an 
epidemic on our hands. 



Turf Battles 



Hughes: Were you aware of a scrambling for turf amongst some or all of 
the physicians? 

Silverman: You're talking about the [Paul] Volberdings and [Marcus] 
Conants of the world? 

Hughes: Yes. A jockeying for what part of this epidemic they were 
going to appropriate. Did that ever come across to you? 

Silverman: No. Volberding moved right up, I think because of his 

personality, his presence. I think there were some jealousies 
there from some who seemed to always be in the shadow. Whether 
that was early, middle, late in the epidemic, 1 don't remember, 
but 1 know there was some tension. 

I didn't get that sense with Conant. 1 had some concerns 
with Conant over the politics, not the medical side of it. We 
worked much better on medical issues than most groups. We 
weren't like the [Robert] Gallos and the [Luc] Montagniers. 
There was a real sharing of information. So I guess the answer 
would be really no. 



117 



[Donald] Abrams and [Constance] Wofsy and Volberding were 
doing their thing, and that seemed fine. The other medical 
elements of the city weren't falling all over themselves to 
deal with the epidemic; this was not something that looked like 
it was a winner, if you will. Marc was certainly doing his 
stuff up on the hill [Parnassus, the location of UCSF] . I 
think others at SFGH [San Francisco General Hospital] needed to 
be educated about the gay community and the unique issues 
surrounding HIV/AIDS, and they became educated. Infection 
control I remember was an issue at the hospital [SFGH] that we 
were really concerned about. 

But again, I really got the sense of working together, 
because I remember that infection control committee [UCSF Task 
Force on AIDS] getting together and kicking it around. As I 
say, we're probably pretty unique. Again, it gets back to 
personalities, but people who like to be here [in San 
Francisco] , people who like to be at San Francisco General 
Hospital, are a different kind of breed. 

One of the things that has kept me rejuvenated in this 
fight is the people that are involved, who are some of the most 
outstanding individuals, human beings, I've ever dealt with. 
You can sometimes deal with the other aspects when you have 
that to work with, and we had that. And we had it especially 
in this community. 



Conceptualizing AIDS as a Gay Disease 



Hughes: How were you conceptualizing the disease? 

Silverman: Well, basically as a gay disease. It was not affecting anyone 
else. I don't think we ever believed it would stay just a gay 
disease; epidemics don't stay in any neat little packaged way. 
And it was very interesting, because it was first called GRID, 
gay-related immunodeficiency disease. 

I remember members of the gay community coming in and 
saying, "Listen, everyone's pointing their fingers at us. This 
is obviously not just a gay disease; it's a public health 
problem. Can you not use that term [GRID]?" I said, "Well, 
with regard to terminology, it is like legionnaire's disease-- 
the disease named for those it struck. I'll be amazed if we 
can get away from that term. But I would agree with you that 
it is a public health problem." 



118 



The reason I bring that up is later on, the community 
would come back and say, "Wait a minute, this is a gay disease! 
We need money for the gay community. This is not everyone 
else's problem." So it was- -schizophrenic is probably not the 
right word- -but depending on the time and who was talking, the 
concern changed. 

But at that time, and actually except for a really small 
number of cases, it has continued to be a gay, bisexual disease 
in this city. 

Hughes: Is that how your literature was oriented? 

Silverman: Oh, yes. Until December of '83. I can't remember, but I think 
it was '83, when we saw our first heterosexual case in the 
city. 1 We reported it, even before CDC started talking about 
it. 2 There seemed to be a real reluctance for the government 
to acknowledge the heterosexual possibilities, because I think 
the next question would be, "Okay, what are you going to do?" 
And I don't think they were prepared. 

We acknowledged it; we informed the media. I remember 
doing two public service announcements [1984]. We had a gay 
man do one, and I did the other. The gay man did the one 
directed towards the gay community, and mine was directed 
towards the heterosexual community. With all the pressures 
that were coming about with bathhouses and [AIDS] education, I 
decided, "Why am I doing this alone? This is crazy." 



AIDS Education Programs 



Educational Approach 



Silverman: I believe we got some money as early as December of '81 for the 
Kaposi's Sarcoma Research and Education Foundation to fund some 
education programs- -probably the first monies every asked for 
and spent for AIDS education in the United States. 



: John Jacobs . 
March 2, 1983, B8. 



New AIDS case stumps medics. San Francisco Examiner, 



2 The CDC reported six cases of PCP and/or KS in heterosexuals on August 
28, 1981, but did not comment specifically on them. (Morbidity and Mortality 
Weekly Report 1981, 30:409-410.) 



119 



Hughes: There was controversy about the educational efforts of the 
department . 

Silvennan: Well, there were several. One of then had to do with the first 
poster on the AIDS epidemic which we [the health department] 
designed. Interestingly enough, when the first iteration of it 
was brought to my attention, it showed some almost nude men, 
and I thought, "Wait a minute, this is not where we should be 
at this point in time." I don't know if we used the word AIDS 
at that time or not, but we said, "Reduce your number of sexual 
partners, reduce your drug use, use condoms every time," things 
like that. 

On one side, there were some elements of the gay community 
which said we had no business talking about that. On another 
side, some people, mostly in the straight community, said, 
"This is ridiculous. Why don't you come out and say, 'Stop 
using drugs. Don't have more than one partner.'?" So we 
really didn't satisfy anybody significantly. 

I believed in those days that just coming out and saying, 
"Don't, don't," is like what parents tell their kids, and that 
doesn't work. The whole concept from the very beginning was to 
try and work with the community in education about AIDS. I 
never felt that government was very good at dealing with sexual 
issues. My other thought at the time, as we started getting 
money and directing it out from the department, was that I had 
no idea this disease was going to be with us for so long, and I 
clearly didn't want to add more people to our staff only to 
have to find something else for them to do when this epidemic 
was over. 

My way of managing is trying to bring people around the 
table, trying to get a consensus, ultimately realizing the 
decision is mine, but getting the input from people who very 
possibly have more expertise in that specific area, whatever it 
is, and then making a decision. So very early, we started 
bringing the community in and trying to respond to its needs 
and to provide funding, planning, and oversight, but letting it 
provide the actual services. 



Attacks by Randy Shilts and Harry Britt 



Silverman: I had problems because my education program [of 1983] was being 
hit in the press by Randy Shilts, and by Harry Britt, who at 



120 

that time was the only gay [San Francisco] supervisor. 1 I'll 
never forget, Harry called a meeting for me to meet with him 
and the mayor to talk about the education program. 

We went into her office, and her first question to Harry 
was, "Well, what's the problem with the health department's 
education plan?" He said, "I haven't read it," which I thought 
was very interesting. Then she said, "Well, what would you 
like to see?" He said, "I don't know, because I am not an 
expert in education." I was sitting there scratching my head. 
What's wrong with this picture? He doesn't like the program 
that he hasn't read, and he has no idea of what he wants. What 
are we sitting here for? It was really a bizarre situation. 

But for some reason, Shilts was carrying this and running 
it [in the Chronicle]. He'd come in and I'd lay out this whole 
educational program to him, and then he'd go and find somebody 
who might not like it and then write the whole article that 
way. I remember he talked about the [health department's] 
lackluster AIDS education plan. The thing was, he didn't say, 
"So-and-so said it was lackluster." Lackluster was his word, 
and that's not reporting. That's commenting. It's opinion. 
So I finally got tired of this really biased treatment. In 
fact, I got so upset- -obviously, none of us like to be 
criticized, but it's okay if at least there's balance- -that I 
cut him off from access to me. 

He ended up writing me a note saying, "I'm sorry, you're 
right, I shouldn't do this, and I promise not to do it again." 
Not promise not to be critical, but promise not to be so biased 
and one-sided. I used to call his editor and say, "For God's 
sake, put him on the editorial page." 

Hughes: The health department's AIDS Activity Office was formed in 

1983. Fairly close thereafter, the department came up with a 
seven-page AIDS education plan. Do you remember that? 

Silverman: Vaguely. I think that's the plan I'm talking about. 

Randy has done some very important things for the AIDS 
movement, and for getting the information out. But he was not 
an objective, unbiased reporter. He was really stirring up 
diverse reactions in the gay and general community. 

Hughes: There was an article in the Chronicle in September of '83, and 
I'll quote: "A growing number of city leaders believes that 



1 And the Band Played On, p. 376. 



121 



San Francisco's emergency AIDS education program has produced 
few results for the hundreds of thousands of dollars of city 
money spent this year [in 1983]. Bl That was the money that 
the health department then turned over to Shanti and the 
AIDS/KS Foundation. 

Silverman: Yes. I can't speak specifically to that. It would be 

interesting if [San Francisco Board of Supervisors President] 
Wendy Nelder's name is in that article. 2 After interviewing 
me, Shilts went over to Wendy Nelder and said, "What don't you 
like about what's happening?" 

I realized that my mistake was not keeping the supervisors 
up to date. So I went over and met with her, and she 
apologized after I explained what we did. She said, "I never 
knew what you were doing." What I really wanted to say was, 
"If you didn't know what we were doing, why did you comment?" 
And from that point on, she was totally supportive. You can 
follow that, as you look at the press after that and at the 
minutes of the meetings of the board of supervisors. She 
became totally supportive of what we were doing. My mistake 
was not having kept her informed. 

This doesn't mean it was the perfect educational program. 
I can't even tell you now what the contents of that program and 
plan were. The thing was, it was the only one in the world. 
And we were all looking to find out what should be done. You 
had some factions within the gay community saying, "Don't air 
our laundry in public. We have gay liberation now. Don't 
start throwing us back into the closet by discussing our sexual 
activities and what we shouldn't be doing." Another group was 
saying, "Listen, our brothers are dying. Get the information 
out there!" So there was no unanimity in the very group we 
were trying to reach. 

It sounds like I'm protesting too much, and maybe I am. 
Randy's book maintains that I was playing to the gay community 



*Randy Shilts. S.F. wonders where AIDS money goes. San Francisco 
Chronicle, September 22, 1983, Al. 

2 Nelder is quoted twice: "We passed the money because it was an 
emergency- -we wanted something urgently done. We haven't seen results. 
[Dr. Silverman] had better be ready to have some answers." In reference to 
the health department's AIDS education plan, she was quoted: "If this is 
all the documentation [the health department has], then they wouldn't have 
gotten money from agencies I've worked with before. We pay Dr. Silverman a 
lot of money to be professional. Where is the professionalism here?" 



122 



as if there was some political benefit. The gay community was 
the community I was trying to reach with the message. And if I 
wasn't reaching them, I wasn't doing my job. So obviously, it 
was very important to me to know what they were thinking, why 
they were thinking it, and to have them listen to what the 
health department, through these various agencies, was trying 
to accomplish. That was my goal. In fact, the closing of the 
bathhouses needed to be an educational message, not just 
closing some buildings. That doesn't change sexual behavior. 
It's whether closure has an impact on the community, and what 
is that impact. 

Is the impact, government is again controlling behavior 
and controlling the gay community, and it's sodomy laws, and 
this, that, and other things? Or, is the perception that the 
health department is there as our partner; we're trying to work 
together to put an end to this epidemic? That's a much 
different type of thing. I don't think you get people to 
change behavior by force. I think you get it through compliant 
behavior based on behavior change that has come about as a 
result of education and information. 



Diversity vtthin the Gav Community 



Hughes: Well, some of your problem, as you've touched on, was the fact 
that there really wasn't a unified community position, at least 
in the political sense. There was a schism in the gay 
community that to a certain degree lined up with the two main 
gay Democratic clubs. 1 Would you put it that way? 

Silverman: Pretty much. It was the [Alice B.] Toklas and the Harvey Milk 
[gay Democratic clubs). Oh, yes, for anyone to assume that the 
gay community is somehow monolithic is a mistake. I think the 
only thing that they probably can agree on is that people 
shouldn't be discriminated against because of sexual 
orientation. That's where it stops. You get every political 
color and stripe. You've got the Stonewall Club, which is 
Republican. The infighting amongst the [gay] groups I guess is 
as much as amongst any other groups. 



*Randy Shilts. The politics of AIDS. San Francisco Chronicle, June 
11, 1983. John Jacobs. Gay political groups swap charges over AIDS. San 
Francisco Examiner, June 26, 1983 (Gay and Lesbian Historical Society 
folder: AIDS 6-7/83). 



123 



I really think people's concept of the gay community, and 
I'm not gay so I had probably had a similar concept, is that 
it's a monolithic group. And it's very clear that it Just 
isn't. The community is made up of lesbians and gay men, and 
there are certainly many differences between them and within 
them. 



Complexity of the AIDS Problem 



Silverman: But you couldn't, nor can you today for the most part, get 

agreement by everyone affected on any single issue. AIDS is 
really somewhat unique that way. There is nothing simple about 
it. When you think you've got something solved and you move it 
aside, it will come back. 

Hughes: Why? 

Silverman: Well, I think there are several reasons. One, you have a 

devastating disease that is attacking people at an age when 
one's own mortality is hardly even thought about. I mean, 
young people, teens, early twenties, unfortunately they think 
nothing can happen to them, and here all of a sudden they have 
to face their own mortality when their friends are dropping 
like flies. And not just dropping, but dropping in a very 
tragic, tragic way. Dying from any disease is not very 
pleasant, but dying from AIDS is I think one of the worst. 

Then you had a group in which many had finally gotten a 
sense of self, as far as community and individual were 
concerned. Here was a caring, supportive community in San 
Francisco. They could walk down the street holding hands and 
not have to worry about being beaten up like they might in some 
other place. So gay liberation had taken place; they were 
really on a roll. Then the epidemic came along. 

Also, you had a disease which affected a community. 
Cancer cuts across all communities, and AIDS to some extent 
does. But in San Francisco, this was basically and still is 
basically a gay disease. So you had an already organized, not 
necessarily homogenous but organized community to then get 
involved in fighting the epidemic. 

In those early years, we didn't know what it was that was 
doing it. We had an idea it was related to sex, because what 
is unique about gay men is their sexual orientation and 



124 



activities. And so there were so many things coming together, 
a confluence of things hitting all at the same time, that I 
think It's not surprising that there were controversies. In 
fact, once you get past the tragedy of the epidemic Itself, the 
thing most tragic to me is the backbiting and infighting that 
still exists amongst and within AIDS organizations. I see It 
internationally; I've seen It all over the world. 

Plus, because the epidemic was new, all these 

organizations, not necessarily the gay political organizations, 
but these other organizations were also new and growing and 
maturing and going through what I like to call adolescence. It 
seems like every organization, mine [American Foundation for 
AIDS Research] included, had to go through that. People are 
Involved In many AIDS organizations, not because It's nice to 
be Involved but because their life, they feel, depends on it. 
This creates an incredible sense of urgency. 

So all of these things come into play. Probably no single 
one more important than others, but all of them come into play, 
making the AIDS epidemic one of the most complex things that 
I've ever dealt with. And because of the administrations we've 
had in Washington, one of the most "political" diseases I've 
ever dealt with or have read about. 



The AIDS Activity Office 



Hughes: Let's go back to the health department itself. I know what 
Selma Drltz was doing. 1 Who else was directly involved with 
the epidemic? 

Silverman: Well, I'm trying to think- -Pat Norman was. Also the person 

[Cunningham] whom I appointed to head the AIDS Activity Office, 
which I set up in '83. He had been In public health; he had 
run a health center in San Francisco. 

Hughes: Why was he brought back? 

Silverman: Well, quite honestly, I needed someone who could be fairly 
objective, and I felt he could be, more so than some of the 
people who were In the department. I thought he could handle 
it in a very professional way. 



1 See the oral history in this series with Dr. Dritz. 



125 



Hughes : 



Silverman: 



There is in some people who finally [publicly] come out 
[as gay] an all-consuming involvement in that issue. I've 
said, whether it's in the foundation that I'm running now or 
the health department, when they're health department employees 
or they're foundation employees, that is the first thing, and 
then their gayness or their blackness or their greenness or 
their Jewishness or whatever can come after that. 

But unfortunately, especially when people are just coming 
out, the issue of gayness becomes quite of ten- -and I'm 
generalizing- -overpowering. That first poster on AIDS was an 
example. Even though San Francisco is a relatively open 
community, this was much too strong for the first poster. But 
this was what was in their minds. They thought naked men would 
be fine. 

Sometimes in the foundation that I'm with, the American 
Foundation of AIDS Research, some young men to whom the gay 
scene is very important make decisions which make sense in that 
arena, but not necessarily for what the foundation is trying to 
do. 

A classic example: I remember someone once wanting the 
foundation to sign on to a letter decrying the immigration 
policies vis-a-vis homosexuals. I said, "All of us are upset 
about it, but that's not an AIDS issue. Give me a letter that 
says, "We decry the immigration policies related to AIDS,' and 
you've got it [the support of the foundation]. But not the 
other. " 

It's a long way around, but in this situation [appointing 
a director of the AIDS Activity Office], I didn't think Pat 
Norman, to be quite frank, could give that kind of objective 
approach, and that's what I needed. She was very upset, 
because she thought she was the heir apparent to that position, 
[tape interruption] 

How did you envision the AIDS Activity Office operating? 

Well, its basic function was to do almost what the Lesbian and 
Gay Coordinating Committee did- -well, actually much more so. 
Obviously, we wanted to be sensitive to the services we were 
providing and make sure we were providing relevant services in 
the area of AIDS. This would be an office that would get 
requests for support, would review and provide the grants, and 
would provide fiscal oversight and what have you, of the 
various [AIDS] programs that we were funding. 



126 



So the office really was the focus of the AIDS program in 
the department. It was a resource for me to go to, to follow 
up if the hospital [San Francisco General] wanted to put in an 
inpatient unit, or somebody wanted to set up another screening 
clinic, or start an education program- -whatever it was. It was 
like having a TB [tuberculosis] unit or STD [sexually 
transmitted diseases] unit or what have you. 

Hughes: And did it indeed function in those capacities? 

Silverman: Yes, I thought so for the time that I was there. I gather it's 
grown tremendously, but when I was there, it was basically a 
small office. 

Hughes: Did that mean hiring people? 

Silverman: Yes. There was support staff, two to four- -I just don't 

remember. It was a very small office. I gather now there are 

over ninety people in the AIDS office. But this was slim 
pickins then. 



Selma Dritz 



Hughes: How directly aware were you of what Selma Dritz was doing in 
the health department's Bureau of Disease Control? 

Silverman: Well, we were in contact quite regularly, especially as we got 
involved with the bathhouse thing. She was very much involved. 
She was the obvious resource of the epidemiologic information. 
She was also the source of some other information. I will 
never forget, she made it clear to me that it was [pronounced] 
Kaposi's sarcoma, not KapcSsi's sarcoma, and even gave me some 
historical information. She was a very good, very level-headed 
person dealing with this epidemic. I think she was the perfect 
person in that role at the time . She is to be played by Lily 
Tomlin in the upcoming HBO movie [based on And the Band Played 
On]. It was going to be Whoopie Goldberg, which would have 
been a real kick. 

I sought, and also without my seeking it, Selma would 
provide counsel to me on these issues. I don't know that we 
always agreed. I don't remember exactly the kinds of things we 
discussed, but she was a very good resource. 



127 



Hughes: She herself had had considerable experience with the gay 

community prior to the AIDS epidemic in following sexually- 
transmitted diseases. 

Silverman: I believe so. 

Hughes: Well, the health department in July 1981 established a 
reporting system and registry for AIDS cases. 1 Do you 
remember that? Was that something that Selma instituted? 

Silverman: Oh, I'm sure it was something that Selma started, to try and 
get a handle on what was happening in this community. 

Hughes: Then there was a registry of physicians throughout the state 
who were willing to care for AIDS patients. 

Silverman: I wasn't involved in setting it up, because I wasn't the 

implementor of these things. But I remember, we were hearing 
from the AIDS clinic that it was getting overwhelmed, and there 
needed to be physicians that we could refer patients to. It 
was also another way of getting the other hospitals to start 
caring for these patients, because if they were admitted from 
private doctors' offices, it was easier to have them admitted. 
So it was a subtle--! don't know the word- -sort of a way in 
which to get HIV- infected patients into many hospitals. 



Hospital Admission of AIDS Patients 



Silverman: In fact, I remember one of the hospital administrators who I 

had been meeting saying, "Listen, we're not going to put a sign 
up that say, 'AIDS, y'all come,' but if they come in and 
they're admitted, we obviously are going to take care of them." 
And in fact, most of these people with AIDS had private 
insurance. That was money for the hospitals. 

But the hospitals couldn't come out- -if you will- -as 
favoring their admission, so we set up this registry as an 
attempt to both take some of the load off the AIDS clinic, Ward 
85, but also to get the AIDS patients into other hospitals 
without any problem. 



F. Silverman. San Francisco: coordinated community response. 
In: AIDS: Public Policy Dimensions. New York: United Hospital Fund, 
1987, pp. 170-181, p. 171. 



128 

Hughes: So in terms of the hospitals, admitting AIDS patients was a 
monetary issue; they wanted to fill their beds. 

Silverman: Yes. If you talked to the administrator privately, he wanted 

to fill the beds because we had a lot of empty hospital beds in 
this town. Publicly, as I say, they couldn't come out and make 
it clear, because they were afraid they'd lose other potential 
patients who might fear coming to what they might imagine was 
an AIDS hospital. 

Hughes: There is documentation that UCSF was not interested in having 
AIDS patients for a variety of reasons. 1 

Silverman: You mean up at Moffitt [Hospital] . 

Hughes: Yes. And that was one of the rationales for moving AIDS 

activities to the General [San Francisco General Hospital]. 

Silverman: Well, I don't think it was moved. It was begun there. 
Hughes: Well, remember, the KS clinic was at UCSF. 

Silverman: The KS clinic was, yes, but the inpatient and outpatient AIDS 
activities were at San Francisco General. 

Hughes: Well, you could argue that they could just as easily have been 
established at UCSF, if the administration had wanted to. 

Silverman: Oh, sure, if there was an interest. I think that's probably 
true. 

Hughes: Was there ever a period when hospitals said, "This is a disease 
that nobody knows anything about. People are dying with no 
means of cure. We don't want these patients." 

Silverman: Well, I never heard that voiced from UCSF. 
Hughes: What about at the other hospitals? 

Silverman: Other hospitals were worried about having these patients 

because of what it would do to the other patients. Hospital 
administrators feared the presence of AIDS patients would keep 
non-AIDS patients away out of concern that AIDS patients would 
spread the disease. I think there was a real fear of that. 



l And the Band Played On, pp. 480-481. 



129 



Initial Opposition to the AIDS Ward 



Silvennan: Interestingly enough, because we had the dedicated unit [the 
inpatient ward] at San Francisco General, people who could 
afford to go elsewhere came to General, because it was the best 
AIDS service, the best care you could get anywhere in the 
country. It was a unit that I initially, as you've probably 
read, was opposed to. 1 Not opposed to, but reluctant to 
accept, because I feared it would have the stigma of and be 
like a leper colony. Fortunately, I was convinced otherwise. 

Hughes : By whom? 

Silverman: Oh, I guess Paul Volberding and others. And ultimately, 

probably also Cliff Morrison, who I think did an absolutely 
superb job in setting up that ward and running it. As I say, I 
tend to run by consensus . When people who seemed to have a 
sense of the need for a dedicated unit made it very clear, I 
certainly acceded to that and said, "Well, let's try it and see 
what happens." It didn't take very long to see that it was not 
only just a good idea, but it was something that was an 
absolute success. In fact, too successful, because there were 
too many patients for the unit to serve. 

And it wasn't our purpose to save money by implementing 
the San Francisco model of AIDS care. Our purpose was to 
provide the best care. The spinoff was we reduced hospital 
length of stay. We could probably reduce hospital stay to a 
greater degree in the gay population than in the drug-using 
population. So instead of going from sixteen to eleven 
hospital days, maybe we would go from twenty-two to sixteen. 
In other words, I'm not expecting the same absolute results in 
other communities, but the relative results can be there. I 
think if you don't have a program, there's going to be a higher 
cost in human and economic terms; and if you have a program, it 
will be a lower cost in both areas. 

Hughes: Could you have stopped the creation of the ward? 

Silverman: As director of health, oh, yes, of course. I just would not 
submit for the funding, or I could turn it down. 



F. Silverman. San Francisco: coordinated community response. 
In: AIDS: Public Policy Dimensions. New York: United Hospital Fund, 
1987, pp. 170-181, p. 172. 



130 



Hughes: You would have done so on the basis of the argument that it was 
discriminatory? 

Silverman: Well, it could appear that the unit was set up to protect other 
patients like leprosariums were established years ago 
(unnecessarily). And there was also the argument, "Don't we 
really want every nursing service to be able to handle AIDS 
patients?" In fact, when I became director of the Robert Wood 
Johnson AIDS Health Services Program the year after leaving the 
health department [1986], it was to have a demonstration 
project throughout the country, based on the San Francisco 
model, as it came to be known. I was not one that said you 
absolutely had to have a dedicated, inpatient unit. It would 
depend on the community and the numbers of AIDS cases and other 
factors . 

My ultimate goal was always to have AIDS become 
mains treamed, but not normalized. By mainstreamed I mean that 
no matter what ward AIDS patients went on, no matter what unit, 
whether it was cardiac or whatever, there would be trained 
staff that could handle people with AIDS. Not normalized, in 
that AIDS not get treated like heart disease, which gets 
attention every February as National Heart Month or what have 
you, but otherwise is not considered by many as a health 
crisis . 

AIDS must receive proper attention, but it ought to be 
integrated not only into the hospital but into the entire 
health care system. 



San Francisco's Unique Response to the Epidemic 



Hughes: What was unique about San Francisco's response to the epidemic? 

Silverman: Well, first of all, we had several things going for us. One, 
that the disease was primarily in the gay community. New York 
had the gay community and very quickly the drug-using 
community, two totally different communities- -not that there 
isn't some overlap. You could tell even in the dedicated 
inpatient unit, the desire to take care of people who were 
using drugs as opposed to gay men was quite different. Gay men 
were compliant, cooperative. Working with a gay man is a lot 
different than working with someone who is always trying to con 
you, the way some people who are addicted to drugs are. 



131 



Secondly, we had a budget surplus instead of a budget 
deficit, which was unique. 

Thirdly, we had a very supportive mayor. So the executive 

branch was supportive, the legislative branch was supportive, 

and the community in general, obviously with some exceptions, 
was very supportive. 

Hughes: Did personalities enter in? 

Silverman: Personalities? The mayor, Feinstein, and I obviously had our 
disagreements, but I don't think she ever turned down any 
funding request that I brought to her. The personalities on 
the board of supervisors obviously supporting it. 

Hughes: You were a consensus -builder , which made a big difference. 

Silverman: Yes, and I was interested in the epidemic. There are health 

officers in other cities who still don't want to touch it with 
a ten- foot pole, probably because they read about what I went 
through. [laughs] 

Hughes: It would have been hard for you to avoid dealing with the 
epidemic. 

Silverman: Absolutely. But if I had tried to avoid it, then I would 
probably have been removed, because I would not have been 
providing for the city's needs, and somebody else would have 
come in. Obviously, whether I was the person or not, somebody 
who understood the situation and was involved in the community 
in planning and implementing the government's response would be 
necessary here. Personalities were very, very important. 

The community was very supportive. I remember walking 
over to City Hall one day- -my office was right on the corner 
across from City Hall --and this woman came up to me pointing 
her finger at my chest saying, "As a native San Franciscan, "-- 
and of course, once she said that, she already had me, because 
I wasn't born here, and even if I stayed here a thousand years, 
I'd never be a native San Franciscan. She was very concerned 
about all this money spent on and interest about AIDS. There 
were some people that were opposed. But for the most part, 
this was a very, very supportive community, a very caring 
community. 

You can see that just in the per capita expenditure for 
health care in the city. Probably the only place that exceeds 
it is Bahrain or somewhere in the oil-rich Middle East. You 
figure it out: I think we're up to about $500 million now, 



132 



divided by the San Francisco population of 750,000- -that' s a 
hell of a lot of money per person in a community for public 
health care. So this community has always been supportive of 
meeting its health care needs. 

New York had garbage problems and this problem and that 
problem. AIDS was just one of a thousand major unsolvable 
problems in New York City, though I still think they didn't 
handle it appropriately at all. But they had so much more on 
their plate. That's another one of the benefits that we had; 
though we certainly had problems, they just weren't of the 
character nor the quantity that a city like New York had to 
deal with. 

Hughes: In a sense all you players were politicians; you had to be. 
How much do you think Feinstein and the board of supes and 
other politicians were motivated by the knowledge that gays 
were politically active, they were voters? In other words, if 
you were a politician and wanted to get reelected, you'd better 
listen to what they were saying and what they were needing. 

Silverman: I think that's a factor. I don't know how much weight to put 
on it. I do think it's the character of the city to be more 
caring than most cities, but no one should ignore the political 
power of the gay community. 

Hughes: What were Feinstein' s motivations? 

Silverman: Well, I would like to believe it was for humane reasons, and I 
really believe that for most of the time. I saw some changes 
when she thought she might be in the running for the vice 
presidency. She all of a sudden distanced herself and had me 
be the point person from the city side --although I was the 
point person from the health side- -when we went to the U.S. 
Conference of Mayors meetings. Prior to this time she would 
publicly deal with AIDS issues. 

But I still have to believe that she is a basically humane 
individual. I don't know that all her motives were based on 
the health issue. I think part of her interest was to clean up 
the city. She really had a real problem with the fact that we 
had sex clubs and bathhouses in this city. My feeling was, 
it's not the role of the health department to "clean up" the 
city; it's to make sure that there are not any unhealthy 
situations in the city. It's like inspecting restaurants: the 
food may taste lousy, but if it's not unsafe, it's not my role 
to interfere. 



133 



The Health Director's Povers 



Silverman: The power of the health director is, to use a "Valley" tern, 

awesome. It really is. I could have closed City Hall; I could 
close a police station. In fact, I overrode the police and 
fire departments when we had a transformer burst down in the 
financial district, putting out PCBs [polychlorinated 
biphenyls]. I went down there first thing in the morning. 
They were getting ready to open it up, and I was sliding on the 
PCB oil on the sidewalk. I said they couldn't open it, and I'm 
sure millions of dollars were lost during that time. That was 
my decision. 

Now, if I used my power capriciously, I could be in 
trouble. But otherwise, the power is incredible, and I think 
that you use it very cautiously, very carefully. My feeling 
was, if you don't like sex clubs, you have a political way to 
deal with them. They weren't even licensed. If you were not 
licensed, what are you looking at the health department for? 
License them, and then have the health department regulate 
them. But there was no political will, there was no political 
commitment to do that. I think the mayor and probably some 
others would have liked to have had the health department do 
that for them. As I say, that wasn't our role. 

Hughes: These powers that you're talking about, are they unique to San 
Francisco? 

Silverman: No. 

Hughes: They are common to any health department. 

Silverman: Yes. 



The Health Director's Medical Advisory Committee on AIDS #) 

Hughes: In March of 1983, you formed an ad hoc medical advisory 

committee to "keep abreast of developments and present as 
consistent a response as possible to the public on matters 
relating to AIDS." 1 



F. Silverman to Marcus Conant, March 11, 1983. (Marcus Conant's 
KS notebook for 1983.) 



134 



Silverman: Couldn't have said it better myself. [laughter] 
Hughes: Do you remember the people who were on that committee? 

Silverman: Well, Marc [Conant] was on it. Paul Volberding was on it. Who 
else did I have on that? I'm sure the files will show. I had 
several gay physicians from the community, Bob Bowen, and Rick 
Andrews - - 

Hughes: Who is he? 

Silverman: He's a psychiatrist. And I had someone representing the 

hospitals, and someone representing the medical society. I 
just don't remember who. I am blanking on exactly who was 
there . 

Hughes: Did you attend those meetings? 

Silverman: Yes. I ran them. 

Hughes: Can you give me a feeling of what went on? 

Silverman: Well, we'd bring in a representative from BAPHR [Bay Area 

Physicians for Human Rights]. We'd discuss the issues of care, 
not only at General but at other hospitals. I think the [AIDS 
physician] registry probably came out of that. 

If there was a new finding, we tried to bring it to the 
table or someone else could bring it to the table, trying to 
update all of us as to what was topical. Selma I know was part 
of that committee. Maybe Don Abrams was; I'm not sure. 

It was basically to monitor what was happening in 
reference to the epidemic, what we were doing from the public 
side. Again, it's this idea of bringing together the various 
players, as the statement said, so as to have a united front. 
Not to be in lock step, no conspiracy. But if we all knew that 
something was wrong, we could all go out and say that. So we 
didn't issue misinformation which was confusing to the public. 
Of course, part of the reason was that we didn't know all the 
answers, but on issues we agreed, we could all say the same 
thing. The committee was intended to cut down on the confusion 
and unnecessary fears. 

Hughes: And were you successful? 

Silverman: I don't remember- -we didn't seem to have people going every 
which way. So I think in a sense it was successful. You'd 
have to ask them. 



135 



The Community Advisory Coamlttaa on Aing 

Hughes: Well, in addition to the medical advisory committee, there was 
a general AIDS advisory committee, which I believe was 
established at the same time, with members from the gay 
community. 1 Anybody else? 

Silverman: I really don't remember the exact composition. I had an ad hoc 
committee around the bathhouses that was separate from these 
two. 

Hughes: Those committees presumably met separately. 
Silverman: Yes. 

Hughes: Did you always attend the community AIDS advisory committee 
meetings? 

Silverman: I'm sure on occasions I attended, but I don't know that I was 
there all the time. I set up the medical committee directly 
for me , sol was always in attendance . 



AIDS Screening Clinics 



Hughes: Well, as the number of AIDS cases increased, screening clinics 
were added at two city health centers. 2 

Silverman: Yes, we had one at District Health Center number 1 on 17th 
Street. And then we set up another one in Health Center 2, 
which is over in the Western Addition. I don't remember what 
street it was on [1301 Pierce Street). 

See, this is how the model grew: as the AIDS clinic at San 
Francisco General seemed to be getting overwhelmed, then we added 
screening clinics elsewhere. It was like, "We'd better see if we 
can set up screening clinics, so we take some of the burden off of 



^ervyn F. Silverman. San Francisco: coordinated community response. 
In: AIDS: Public Policy Dimensions. New York: United Hospital Fund, 
1987, pp. 170-181, p. 174. 

2 Mervyn F. Silverman. Addressing public health concerns of the city 
of San Francisco. In: AIDS and Patient Management: Legal, Ethical and 
Social Issues. National Health Publishing, 1986, pp. 27-35, p. 31. 



136 



the AIDS clinic at SFGH." So what you had was the net getting 
smaller and smaller. As you moved to higher degree of service, 
you had the screening, the clinic, the inpatient unit. 

Hughes: Do you know anything about the questionnaires used in the 
screening process? 

Silverman: Not really. Of course, when we set the screening clinic up, we 
didn't have the HIV antibody test, so screening was obviously 
very much based on the clinical findings. 

Hughes: Did adding the screening clinics mean increasing staff? 

Silverman: I'm sure it must have. But I just don't remember. I don't 

remember whether we were able to use existing staff --I'm pretty 
sure we had to add staff. In fact, I'm almost positive we did. 

Hughes: You have implied that funding wasn't a big problem. 
Silverman: That's true. 

Hughes: Was this because of the budget surplus, and because the powers 
that be, Feinstein on down, were behind this effort? 

Silverman: Yes, both. 

Hughes: So you weren't struggling for money. 

Silverman: No. And that's what so unique. 

Hughes: And so very different from the stories I hear about what was 
happening at the federal level. 1 

Silverman: Oh, yes. 

Hughes: What were your ties at the state and federal levels? 

Silverman: Well, at the federal level, I was working with the CDC [Centers 
for Disease Control and Prevention] . And sometimes we were 
setting [AIDS] policy before they did. 

Hughes: Explain what sorts of things you told them. 

Silverman: Well, it was a two-way street. They were obviously getting 

much more epidemiologic information than we were getting. We 



, for example, the oral history in this series with Donald P. 
Francis, M.D. 



137 



were always looking to them for trends and how things were 
going. For the bathhouse issue, I had Jim Curran [head of CDC 
AIDS activities] on my little advisory committee, and the 
reason I think he participated is because he saw the bathhouses 
as an issue that needed to be looked at, not just in San 
Francisco. 

I'm sure Selma on a day-to-day basis dealt much more with 
CDC than I ever did, but I was brought down there for meetings, 
consultations; they came out here. 

We talked with them on some regular basis about policy 
issues. I believe the report the UCSF Task Force on AIDS put 
out preceded the CDC's report on what should be done in health 
care settings to reduce the spread of HIV. 1 So there was 
constant dialogue, plus we were involved in various regional, 
national, and international meetings. 



Government's Role 

Hughes: Well, I want to quote another Silverman statement- - 
Silverman: Then it's absolutely true. 

Hughes: [laughs] What else! "The basic concept underlying our 

approach to the AIDS epidemic in San Francisco when I was 
Director of Public Health . . . was that government cannot do 
everything." Do you want to expand on that statement? 2 

Silverman: Yes. When it comes to telling people about sexual behavior, 

government certainly hasn't done nor is it really set up to do 
very much in that area. Witness the kinds of things we've seen 
from the federal government, which have been anemic at best. 



'John E. Conte, W. Keith Hadley, Merle Sande and the UCSF Task Force 
on AIDS. Infection-control guidelines for patients with the acquired 
immunodeficiency syndrome (AIDS). Nev England Journal of Medicine 1983, 
309, No. 12:740-744. The UCSF guidelines preceded those of CDC. For 
details, see the oral history in this series with Merle A. Sande, M.D. 

2 Mervyn F. Silverman. San Francisco: coordinated community response. 
In: AIDS: Public Policy Dimensions. New York: United Hospital Fund, 
1987, pp. 170-181. 



138 



My feeling is that instead of we in government being the 
planners, the implementers , the evaluators- -the everything- -why 
not use the community, which is better able to do it, and has 
better rapport with the people we're trying to reach. And 
again, as I say, I didn't want to expand my empire. My empire 
was certainly big enough. 

When you contract out, that allows for a lot more 
flexibility. You don't have to deal with the civil service 
system, which is an incredibly problematic system. So you have 
much more flexibility, you can get things started much faster, 
you can get the people you need much faster, get the right 
people . 

So government, I felt, should help in the planning, help 
obviously provide the funding, and provide the oversight and 
the evaluation of what's being done, make sure the tax dollars 
are being appropriately utilized. I still believe that. It's 
proven itself. If we left it up to the federal government to 
educate us, we'd be in big, big trouble. 



More on AIDS Education 
[Interview 2: May 10, 1993] 

Strategy 



Hughes: Dr. Silverman, last time we talked about some of the 

educational efforts of the department; I have a few more 
questions on that subject. Did the department consider itself 
one of the main venues, if not the major one, in San Francisco 
for education on the subject of AIDS? 

Silverman: Well, we saw ourselves as not necessarily producing the 

educational material, but seeing that it got out there. That's 
why we used local groups. I think it may have been the 
Kaposi's Sarcoma Research and Education Foundation when it 
began, and then it became the San Francisco AIDS Foundation. 
In the very early years, we didn't know what we were educating 
about; we didn't have a virus and we weren't sure AIDS was 
caused by one. But we were pretty sure how whatever it was 
that was causing it was being spread, and so the education was 
directed more towards behavior- -sexual activities. As more 
information came in, obviously we became more precise in our 
educational activities. 



139 



Hughes: Was it common practice at health departments to not actually 
produce the material themselves but to farm it out? 

Silverman: Probably not in the classical sense. I think in the classical 
sense, the health department produces the health education 
materials and puts them out. I think because of the sensitive 
nature of what we were doing, it was best to have the community 
group put its name on it. In that way explicit materials could 
be disseminated without political repercussions. It seemed to 
me government was never terribly good at dealing with these 
issues anyway. 

Hughes: You mean the health department as a branch of government? 
Silverman: Yes, as a branch of government. 

Everything that was being produced, I reviewed. If it was 
sexually explicit, we just didn't put our name on it. Now, if 
it was being put out by, say, the AIDS Foundation, and because 
they were getting some money from the private sector, we could 
always say, "Oh, that was funded from the private sector. No 
government money." There were a few pamphlets that we just 
said, "Don't put our name on it." Now, the funds obviously 
came from us, most of them, anyway. But they were sort of 
commingled in the financial offices of the foundations. 

And the reason why I think this was good preventive 
medicine was that the Los Angeles department of public health 
didn't do that, and their county commission made them stop 
producing two of their education pamphlets, one of which they 
had used our materials, and one they didn't, both of which were 
quite good. It's like the NEA [National Endowment for the 
Arts) kind of thing. Because we were using taxpayers' money, 
we couldn't be saying things of that sort. 

Hughes: Homophobia was the problem? 

Silverman: No, more the explicitness of the sex. As an example, one of 

them in L.A.--it was a very cute ad--was of a little woman and 
a big hulk of a guy, and she says, "Listen to your mother: use 
a condom every time" or something like that. Very cute, very 
nice, whimsical, it caught your attention. The L.A. county 
commission didn't allow that ad to go public. 

If government has its name attached to something which 
causes controversy, it can become a problem. If the name isn't 
on it, the only thing the public can say is, "Why is this 
coming out?" And they can raise hell about the source, but it 
doesn't come back to the government. 



140 



Hughes: Was that your strategy? 

Silverman: Yes. In fact, I vividly remember reading something and saying, 
"I think this is good, but boy, we just can't put our name on 
it." And we didn't, and it never was an issue. Now, whether 
it would have been a problem in San Francisco, I don't know. I 
just didn't want to have to face that when there was so much to 
do. 



More Criticism 



Hughes: I'd like to read a quote, dated May 4, 1984, from Randy Shilts' 
book: "The prevention program was not the only controversy 
snaring the mayor in May. The bathhouse issue was stalled, as 
was the city's AIDS prevention campaign. Silverman 
subsequently said he was disappointed with the AIDS education 
campaign mounted by his department and the San Francisco AIDS 
Foundation, although he never expressed his reservations in 
public. He felt he had no choice but to include all the 
various gay factions in his considerations, aware that any one 
of the groups would move to sabotage prevention efforts if they 
felt excluded. As he said later, it was better to have all the 
Indians inside the tent pissing out than to have them on the 
outside pissing in." 1 

Silverman: That's actually a phrase of Lyndon B. Johnson; I can't take 
credit. I honestly don't remember what Shilts was talking 
about. I would be happy to tell you if I could remember. In 
retrospect you can always see things that could have been done 
better. 



Citv Money for AIDS Services 



Hughes: Well, in 1983, there was a flap over whether money for AIDS 
services should come from the health department's budget for 



l And the Band Played On, p. 453. 



health care for the poor. Feinstein refused to appropriate 
money for AIDS services from the budget surplus. 1 

Silverman: That surprises me, because, although she and I may have had our 
disagreements, I don't remember ever going to her with a 
proposal for funding for AIDS services and having been turned 
down. 

[tape interruption] 

Silverman: Sal Roselli [of the Alice B. Toklas Lesbian/Gay Democratic 
Club] was reacting to the fact that the mayor's office had 
taken $500,000 budgeted as a reserve fund to provide health 
care to the city's poor and given it to AIDS. Feinstein said 
that the $500,000 reserved for the health care of medically 
indigent adults had become unnecessary because the poor were 
supposed to go to San Francisco General Hospital. So the mayor 
insisted that no worthwhile programs would get thwarted because 
of AIDS appropriations. Some leaders were worried that AIDS 
might become the whipping boy, I think they used that term, for 
why the money was going into AIDS rather than into some of the 
welfare programs. 

Hughes: There was an article in the Chronicle about this time, saying 
that because there was a scramble in the health department for 
AIDS funds, there was fear that other health department 
programs, particularly community clinic services, would be 
cut. 2 

Silverman: Yes. And to my recollection, none of that ever took place. 

Hughes: Yes, largely because there was a budget surplus. You said that 
in the first interview. 



: Warren Hinkle. Flap over funds for AIDS. San Francisco Chronicle, 
October 12, 1983. (Gay and Lesbian Historical Society, folder: AIDS-8- 
12/83.) 

2 San Francisco Chronicle, October 12, 1983. (Gay and Lesbian 
Historical Society, folder: AIDS August-December, 1983.) 



142 



The Census Track Study. 1983 



Hughes: [Andrew] Moss, In his Interview with me, said that he showed 
you and Pat Norman his census track data. 1 Remember that 
early study he and Mike Gorman made in the Castro, which was 
later published in the Lancet? 2 

Silverman: Yes. 

Hughes: He expected some sort of response from the health department, 
which he didn't feel he got. Do you remember anything about 
that? 

Silverman: Vaguely. Let me see how to put this. The results of that 

study were no surprise. If you go into the Castro, which has 
the highest concentration of gay men in San Francisco, and you 
find a higher incidence of AIDS in the Castro, what does that 
tell you? We were focusing our messages on the gay community. 
We were focusing them into the Castro district. As I said, we 
had a screening clinic at the health center number one over on 
17th [Street]. I remember people responding, and my scratching 
my head and saying- - 

Hughes : What ' s new? 

Silverman: Yes. It's almost like saying, when you go to Miami Beach, 
there's a lot of problems with people who have chronic 
ailments. Yes! Miami Beach is full of old people! [laughter] 

Hughes: Well, what might have been news was that the study showed that 
one in three gays was infected. 3 

Silverman: That I don't remember, but it could be. But I guess the lack 
of any major response from the health department had a lot to 
do with the fact that there wasn't a lot of news there. 



: See the oral history in this series with Andrew R. Moss, Ph.D. 

2 Andrew R. Moss, Peter Bacchetti, Michael Gorman, et al . AIDS in the 
"gay" areas of San Francisco. The Lancet, April 23, 1983, 923-924. 

3 See Moss oral history. 



Silverman: 



Hughes : 



143 



The Bathhouse Episode . 1983-1984 



Regulation Rather than Closure 



Now, this of course was in the middle of the bathhouse 
controversy. I'm not sure what Moss' position was. I think he 
was for closing the bathhouses. 

Yes, he was. 1 



Silverman: Of course, the results of his study provided further ammunition 
to close them. By mid- '84, the bathhouses were being 
inspected. I don't know the exact date I sent in the 
inspectors. I happen to have a chronology. [pulls out paper] 
"Fall [1984], health department hires private detective." As I 
mentioned, I had this ad-hoc advisory committee on the 
bathhouses that I had put together. When we met the first 
time, we decided rather than closing the bathhouses to go with 
the regulatory approach, which obviously didn't work, because 
Feinstein didn't want the police department involved in it. I 
was trying to keep it out of the police department, but by law, 
the police chief had to make the final decision. 

I even had Phil Lee, who's now the Assistant Secretary of 
Health, chair the session. It was going to be held in the 
health department, but I would have to submit a recommendation 
to the police chief because he had the authority over 
bathhouses --not me. 

Hughes: Now, clarify what you mean by regulatory approach. 

Silverman: The city attorney, George Agnost, thought it made much more 
sense, since there were already regulations in place for 
bathhouses. The health department inspected them for health 
reasons, sanitation, but regulation was under the police 
department, because the police department saw them as fronts 
for prostitution, gay or straight. So the regulations were in 
the police code. Sex clubs didn't come under the regulations, 
because they weren't licensed at all. 

The city attorney said, "Why don't you just expand, add 
to, the regulations, that there could be no sex between people. 
Then the only issue is, if you can get the regulations passed, 
was there sex between people. And if there was, you could 



J See Moss oral history. 



144 



close them." In other words, you don't get Into the whole 
civil liberties question, because you have a regulation already 
on the books . 

So I started trying to get regulations written by the city 
attorney's office; they were being written. Feinstein was 
getting very, very antsy that we were bringing the police 
department in on this, and we shouldn't be doing that. And of 
course, she couldn't seem to comprehend the fact that involving 
the police department wasn't something I wanted to do; that was 
the law. And I even tried to get the responsibility for 
bathhouse inspection and regulations transferred to the health 
department, not because I wanted more responsibilities, but 
because it made more sense. 

Everyone seemed to be in favor of that, including 
Feinstein. Then Harry Britt got worried and figured, "Right 
now the enemy is not the police department, it's Silverman, and 
if you give the health department the power, he's already 
indicated he wants to close them. We don't want to give the 
health department the power." So when I heard that, I realized 
politics wasn't going to let the change in authority go 
through . 

In July [1984], about a week before the Democratic 
National Convention in San Francisco, I was going to have that 
hearing that Phil Lee was going to chair. Feinstein canceled 
it, which I thought was a very interesting thing, since 
Feinstein was saying the only interest she had was in health. 
But she canceled it because she figured with all these 
reporters around with nothing to do until the convention 
started, this would become big news. She was also being 
considered as a candidate for vice president. And she canceled 
it. 

Hughes: It was just too controversial. 

Silverman: Yes. On the other hand, she was saying to me, "You must close 
the bathhouses, if you can save just one life," and yet she 
cancels the very hearings that would have had the same effect. 

When the hearing was canceled, I brought the bathhouse 
advisory committee together again, and people were all over the 
place concerning closure. I decided when I left that meeting 
that I was going to make the decision myself. I had talked to 
enough people; I had involved the community; I had involved the 
experts. That night I went out for drinks afterwards with my 
wife and Jim Curran, who was from the CDC, and said, "I'm going 
to close them. " 



145 

Hughes: When was this? 

Silverman: This would have been some time in the summer of 1984 

City Attorney's Opinion 



Silverman: The city attorney said, "If you want to close them, you must 
have them inspected and detail unsafe behavior." This is the 
information he hadn't given me in the months before that non- 
press conference which you have a news clipping for. 1 He said 
to me --shows how stupid I was about law- -"All right, if you 
want to close the bathhouses, which ones? And why? What have 
you seen in them?" I said, "What do you mean, what did I see 
in them?" He said, "You just can't close them. You have to 
have evidence that whatever your reason for closing them for is 
taking place in them." 

So then we figured, and this is what took some time, we 
can't send in health department inspectors, because people know 
who they are. They've already been there inspecting. So what 
we did was hire private investigators, since nobody knew who 
those people were, and had them go in. They also know how to 
collect visual evidence, and they keep very tight records, so 
it would hold up in court. 

Once we got that evidence , then we proceeded to put up 
signs closing the bathhouses. The theory was, instead of us 
being on the defensive, we should be on the offensive. So we 
closed them anticipating that they would probably open them, 
and then we could get a temporary restraining order. That, 
rather than us forcing them closed and then them suing us. 

Hughes: This represents a change in viewpoint on your part, because I 
believe you didn't enter this episode, which began in early 
1983, with the idea that closure was a good idea. 

Silverman: Oh, well then I guess I've left some stuff out. 
Hughes: Yes, there's a lot left out. Start at the beginning. 



*Randy Shilts. Silverman Delays on Gay Bathhouses. San Francisco 
Chronicle, March 31, 1984 (Gay and Lesbian Historical Society, folder: 
AIDS 1-3/84). 



146 



Silverman: 



Hughes : 
Silverman: 
Hughes : 
Silverman: 

Hughes: 
Silverman: 



Deciding on Education Rather than Closure 1 

All right. It didn't take a rocket scientist to know that the 
types of behavior that were taking place in bathhouses were 
conducive to the spread of whatever was causing this epidemic. 
In those early years, we didn't even know what the agent was. 
We didn't have it. What was clear was that the number of 
people regularly frequenting the bathhouses probably 
represented 5 percent of the gay population. 

That was one of my questions: were there statistics? 
Well, only from some of [Leon] McKusick's studies. 
Which you looked at? 

Yes, all the time. In fact, he was on my advisory committee, 
and his findings were very important in the ultimate decisions. 

Why? 

Because the AIDS-prevention education that was going on in the 
bathhouses wasn't having any effect, and I'll get to that in a 
minute . 

All right, so you have 5, maybe at most 10, percent of the 
gay community regularly going to the bathhouses. And I would 
say 10 percent is a very liberal amount. That means 90 to 95 
percent are not going to the bathhouses. I had to try and 
reach the whole gay community, and change behavior across the 
whole gay community. If the people who were practicing the 
highest risk behavior could be found in one type of venue, then 
it seemed to make sense --instead of closing the bathhouses 
down, because it doesn't stop unsafe behavior everywhere- -why 
not go into those bathhouses and try through safer sex 
pamphlets to focus attention where you have somewhat of a 
captive audience, and a group that is practicing the highest 
risk behavior, if for no other reason than they could have many 
more partners in a bathhouse than they could in the park. 



J See Silverman' s press statement, April 9, 1984, advocating education 
rather than bathhouse closure. (Dean Echenberg papers, Bureau of 
Epidemiology and Disease Control, San Francisco Department of Public 
Health, drawer: Bathhouses, folder: Sex clubs/bathhouse.) 



147 



Hughes: Yes. Perhaps the 5 to 10 percent that you cite should be 

Inflated in terms of the effect that it had. I am presuming 
that this is a very sexually active segment of the gay 
community, and that their activities aren't necessarily 
confined to the bathhouses . 

Silverman: Well, that's true, although I can't really tell you how many 
had sex outside or inside the bathhouses, although there was 
probably some of that data in McKusick's stuff. No question 
about it that bathhouse customers represented the higher risk 
group. But it was also very clear to me that closing the 
bathhouses wasn't going to stop the behavior. It might reduce 
the numbers of partners, the frequency of behavior, but if a 
person enjoys a certain type of sexual activity and he can't do 
it in the bathhouses, then he can do it where many other people 
are doing it, which is in their homes or public bathrooms or 
the parks, or wherever out there on [Highway] 280 where that 
rest stop is on Junipero Serra Boulevard; that's supposed to be 
a big pickup point. And up near here in Buena Vista Park. 

1 also felt that because we were talking about a 90-10 
ratio, that I wanted to make sure that we tried to change 
behavior across the whole community. In order to do that, I 
had to have the community be responsive to and supportive of 
what the health department and its programs were doing. My 
fear was that if I closed the bathhouses, then the health 
department would be seen as the police department, and our 
prevention messages would be lost. Also it appeared very 
likely that the courts would reopen them and then it would 
appear that-- 



Silverman: --Silverman doesn't know what he's talking about. The courts 
have found that it isn't a problem. I'm being very simplistic, 
because the press is often very simplistic. Silverman closes 
down the baths for a health reason; the courts open them up 
saying it's not a sufficient reason. And as you know, when I 
did close them, they were reopened. So in fact, I was right 
about the legal outcome . 

I was trying to get the gay community to take action, to 
force the bathhouses to stop allowing unsafe sex to take place 
in their establishments or close down. The reason why I 
thought this was possible was because a number of years ago, 
some gay bars had only one exit. They were obviously a real 
fire hazard. So people within the gay community tried to get 
these gay bar owners to put other exits in, and some wouldn't 
do it. So they picketed them. They actually brought a fire 



148 



door, got outside of the gay bars, and picketed. And [snaps 

fingers] almost overnight that was changed. So taking a 

similar action with the bathhouses was something they could do 
--if they wanted to. 

My feeling was because I was trying to reach the whole 
community, the action had to go beyond the physical closure of 
the bathhouses; there had to be an educational impact. The way 
to get an educational impact would be to have the gay community 
do it, not the straight community, not the government. 

I kept working with the gay community up to July of '84. 
The reason why that July of '84 is so important is we had the 
Democratic National Convention here. There was a party that 
was given by the Gay and Lesbian Caucus, to which I was 
invited, and I tried there for the final time with a certain 
number of leaders in the gay community to get them to take an 
action against the bathhouses. Especially since there were 
people in the gay community who made it very clear that they 
didn't like the bathhouses; they thought they should be closed. 
But if I closed them, they'd man the barricades in defiance of 
my actions. 

And why would they man the barricades? The pervasive 
argument that turned around even the strongest gay backers I 
had for closing the bathhouses was, if government closes the 
bathhouses in San Francisco, which is seen as this bastion of 
gay liberation, what message does that send to less liberal 
states and communities? And then the next step is, well, 
obviously people get picked up in gay bars, so you close the 
gay bars. And then the sodomy laws would either be enforced or 
reinstated, depending on what the status was in any given 
state. 

I remember having one very important person in the gay 
community who had been supporting me for bathhouse closure, who 
had been active in politics and still is, call me up and say, 
"Merv, I can't support you any more." I said, "Why?" And he 
gave me the above argument. That argument was pervasive, and 
was a very strong argument. The deal was, if the bathhouses 
closed down because they didn't have any business, or they 
closed down because we [the gay community] closed them down, 
that would be one thing. But if you, government, close them 
down, we just can't have that. Not after all the gains we've 
made in gay liberation. 



149 



Paul Lorch's Editorial 



Hughes: Well, one of the illustrations of what you're talking about is 
the editorial by Paul Lorch that appeared in the Bay Area 
Reporter. 1 Certain gay leaders- -Conant was onewere listed 
as traitors. There were sixteen names listed, all prominent 
members of the gay community. 

Silverman: Well, except for Conant and maybe one or two others, all 

sixteen took their names off the list supporting bathhouse 
closure. 

Hughes: The list I'm talking about was in Lorch's editorial. 

Silverman: That list he had was taken from people who initially signed on 
urging me to close the bathhouses, and I'll get to that in a 
minute. 



Press Conference on Regulations, April 9, 1984 



Silverman: I had a press conference about the new regulations that I 

wanted to impose in the bathhouses. I met with people in the 
gay community. I remember vividly it was Sunday night down in 
my offices, and I said, "Let me tell you what I'm going to do. 
I'm going to impose regulations which I think the bathhouse 
owners can comply with. The bathhouses will certainly stay 
open if they comply with them. What I'm saying is no 
penetrative sex between individuals. And the reason I'm saying 
that is, you can't inspect for safer sex. What are you going 
to do? Separate people and see if they are using a condom? 
You can't do that. It's even a greater invasion of privacy, I 
think, than anything contemplated by the health department." 
And I thought they understood that. 

I said, "If you want to have masturbation clubs, that's 
fine. But I'm not going to stand up as the health director and 
talk about masturbation." Well, I gave the press conference, 
and a few of the people who were standing behind me, literally 
standing behind me at this presentation, went after the press 
and said, "I'm not going to support Silverman. I'm sorry, I 
didn't know he meant no sex in the bathhouses." One of the 
first things that really upset me was the fact that you 



l And the Band Played On, pp. 445-446. 



150 



couldn't count on people to maintain their support, which is 
important in an issue which is so sensitive and so intimate. 



Reactions from the Gay Community 

Silverman: I had been saying all along to the leaders in the gay 

community, "If I have your support, then I can move ahead and 
close the baths. I prefer you all to do it, again as a major 
education impact, but at least if I have your support, we have 
that education impact." Then one day, I got a call from Marc 
Conant, who said. "I've got what you want. I've got the gay 
leadership, asking you to close the baths. I have in my hand a 
signed document." What he didn't tell me is why they decided 
to back closure. Why they decided was Larry Littlejohn had 
made it very clear that he was going to put an initiative on 
the ballot to vote on whether the baths should be closed. 
Obviously, Conant and his group thought they'd rather have 
Silverman close them than the public. On a vote like that, 
they definitely would have lost. No question about it. Marcus 
didn't tell me that Littlejohn was the reason for their action. 

It was the night before I stupidly announced that I was 
going to have this press conference [on March 30, 1984] , and 
the stupidity was that I hadn't touched base with the city 
attorney's office. I don't know the exact days, but let's say 
just for the hell of it Monday night I hear from Conant, "You 
got what you want." Tuesday I go to the mayor and say, "I've 
got what we've been looking for. I'm going to have a press 
conference tomorrow." Tuesday night members of the gay 
community say, "Would you please come down to the Valencia Rose 
and talk to people. They're really concerned about this." 

And what ticked me off is I said to Marc, "Will you come 
with me?" He said, "Yes, I'll meet you there," and he never 
showed up. It reminded me of cartoons where there is a bomb 
with a fuse, and someone lights it and hands it to another 
person, [whistles] and then splits. In fact, that night at the 
Valencia Rose, the place was packed but only two people who had 
signed the document showed up, and both of them stood up and 
said, "We were wrong to sign that asking for bathhouse 
closure. " 

Now, obviously it was a stacked meeting, because a lot of 
bathhouse owners were there. When they were talking about the 
safer sex programs we had in bathhouses, interestingly, one of 
the gay men got up and said, "You know, putting a sign up in a 



151 



bathhouse about safer sex Is like putting a sign up In a candy 
store saying sugar's bad for you. Once you're there, it's not 
going to have much impact." I've never forgotten that. He was 
a lone voice in the crowd. 

But just to show you the depth of the concern about 
closing the bathhouses, somebody who was at that time a friend 
of mine had been in my office several days before in tears 
saying, "You've got to close the bathhouses, another friend of 
mine is in the hospital dying and he only had sex in the 
bathhouses." So when I was invited to come down to this 
meeting at the Valencia Rose, I said, "I want you to be there." 
He was there, and they were calling on people. He kept raising 
his hand. He was the last person called on. I was waiting for 
him to say, "We've got to close the bathhouses." Instead, he 
said, "I think we ought to put signs up in the cubicles." I 
said to myself, I'll be damned. This was the person crying in 
my office only a few days before. 

Hughes: What had happened to change his mind? 

Silvennan: The power of the image of government closing the bathhouses, 
plus the peer pressure, was just too much for him. 

So when I came in to work the next morning, I realized 
what I had been promised by Conant didn't exist. The way it 
writes up in Shilts' book is that I was somehow pandering to 
the gay community for political purposes. Politically, I 
needed nothing from them. The mayor wanted the bathhouses 
closed. Roger Boas, who was my immediate boss, was not 
responsive to the gay community. So my actions had nothing to 
do with politics but with public health. 

Randy has Feinstein saying, "Why didn't Silverman have the 
guts to close the bathhouses?" In a sense, it took guts not to 
close the bathhouses. The easiest thing I could have done was 
to close them, the courts open them up, and I shrug my 
shoulders and say the mayor wanted it done. In short, I very 
easily could have responded to her wishes and been off the 
hook. 

A gay man who, sadly, has died, whom I had tremendous 
respect for, said to somebody else who said it to me that he 
thought I was the single person responsible for more people 
being alive in the gay community because of the way in which I 
handled the bathhouse issue. All this back and forth in the 
press over the summer of 1984, which was very stressful for me, 
actually was very fortuitous, because it shrunk the issue down. 
In April, it was a major issue; I'd say my mail was probably 



152 



90-10 against closing the bathhouses. By August, it was 
probably 60-40 for closing them, mostly from the gay community. 

Hughes: Why the change? 

Silverman: I think because it went back and forth in the press, and 

Feinstein was dinging me from her limousine in Washington as 
she was going to see Mondale to become vice president. She was 
really taking hits on me. So there was a lot of dialogue in 
the press, constant dialogue. And I think the issue just came 
down to a manageable size as people had more time to think, and 
there was more dialogue and more discussion. 



Canceling the March 30, 1984 Press Conference 



Silverman: Anyway, I came in the next morning after the meeting at the 
Valencia Rose, and I went to the city attorney's office. 
That's when they told me, "You can't [legally] close the 
bathhouses." They had sent me a memo saying, "If you want to 
close the bathhouses, you can." But then when it got down to 
specifics, they said, "You can't just close them. Have you had 
them inspected for unsafe sex? Do you know which ones you want 
to close, and what the unsafe behavior was?" I said, "Hell no, 
of course I don't have that information." They said, "Well, 
you just can't close them." 

So I walked down the hall, and Hadley Roff, Dianne's chief 
of staff, and Feinstein were there, and I said, "I'm not going 
to close the bathhouses. I can't." Well, I thought Feinstein 
was going to have a conniption. Hadley said, "You can't have 
this press conference." So the decision was, I was not going 
to have it. 

Hughes: Am I right in thinking that the March 30, 1984, press 

conference might have been at the height of the paranoia? 

Silverman: Oh, I think so. 

Hughes: I'd like you to describe the atmosphere. 

Silverman: Well, in Feinstein' s office, it was very heated. 

Hughes: Who was there? 

Silverman: I know Hadley and the city attorney and Dianne, and probably 
her press person at that time. 



153 



Hughes: 
Silverman: 



Hughes : 



Silverman: 



Hughes : 
Silverman: 



This was the morning of the press conference? 

Of what I call the non-press conference. So I walked back 
across the street to the health department, and in my office 
were the people who were going to be standing behind me at this 
press conference. Paul Volberding was there, Marc Conant, some 
physicians in the gay community, some others. I said, "I'm not 
going to have the press conference." The reaction was mixed, 
some people very upset that I wasn't, others I think very 
pleased that I wasn't. I said, "Just for the hell of it, how 
many of you now think I should close the bathhouses , and how 
many think I shouldn't?" The way it comes out in Shilts' book 
is as if that was the determining factor. I had already 
decided I was not going to close them at that time. I left the 
mayor's office knowing exactly what I was going to do. One of 
the problems I had with Randy was his selective listening. His 
version is even going to be in the television movie that's 
coming out this fall, based on And the Band Played On. 

Your mind was made up when you walked in to the press 
conference. 

Oh, there was no question. The city attorney said, "You can't 
do it, because you don't have the necessary evidence to close 
them down." There was not going to be a press conference 
announcing their closure! Randy certainly wasn't in the room 
but had heard I'd taken this vote, and then just assumed that 
that vote determined my decision against closure. 1 I don't 
even know why I did it now, but I think I really wanted to see 
where people were on this issue right then. It was very 
interesting. The psychiatrists were for not closing the 
bathhouses. The clinicians who were seeing the patients with 
the medical problems were. 

And then somehow, and I don't know whether Randy got to me 
or somebody else, but Randy had heard or said, "There are death 
threats against you." That's when I got the bulletproof vest, 
so I went into that meeting with the bulletproof vest. 

Death threats from the gay community? 

I would assume. The straight community wasn't terribly 
concerned about this issue. 

I remember walking into this meeting in a big, big, two- 
story room on the third floor of the health department. I was 



And the Band Played On, pp. 442-443. 



154 



escorted up there by two plainclothes policemen. I think It 
was overklll--bad choice of tenns--ln regard to protection. I 
wore the bulletproof vest mainly for my wife, not for me. I 
really wasn't terribly worried. 

I am used to joking around with the media when I go into 
press conferences --"Hi, Sally, hi Joe, how are things going, 
what's new?" Since I knew something they didn't know, which 
was that I was going to walk in there and not have anything to 
say, it was almost like a Fellini movie. It was sort of out of 
focus- -you know how they sort of blur the picture in a movie. 
I thought I saw somebody standing there with a towel wrapped 
around him. I remember going up to the front, and there were 
more microphones than had ever been placed before me, more 
television cameras than I had ever been before. 

And then I got up and said that I was not going to close 
the baths. I didn't want to be explicit in what I was going to 
do, because I didn't want to tip my hand as to what the Issues 
were. I said something to the effect that there were some 
legal and medical issues that 1 wanted to investigate. 

Hughes: Here's the picture of the press conference. 1 

Silverman: Oh, there it is. [laughs] This was, as I say, just a blur. 1 
walked in, 1 said my few things, got up and walked out. I had 
never done that before, because I've always been very open. I 
said, "I am not discussing the opening or closing of the 
bathhouses at this point. I am looking into facets of the 
issue, some of which have basically nothing to do with 
medicine," which was the legal thing, "and some which do." And 
I'm not sure what the "some" would be. I may have thrown that 
in just to throw people off a little bit. But the real issue 
was the legal aspect. 

Hughes: But wasn't It also this desire of yours to work with the gay 
community, not just to legislate? 

Silverman: And I thought I had done that. That's why I gave you that 

timing. I thought when Conant called me and said, "I've got 
what you want [a list of gay leaders supporting closure]. We 
were there. I have the support." Carole Migden was on the 
list, and a whole bunch of other people. That's why I was so 
exhilarated that we were finally at that point. That's why I 



*Randy Shilts. Silverman delays on gay bathhouses. San Francisco 
Chronicle, March 31, 1984. (Gay and Lesbian Historical Society, folder 
AIDS 1-3/84). 



155 



decided to close the bathhouses. My biggest mistake, of 
course, was calling a press conference before I really 
understood what the legal ramifications of closing the 
bathhouses were. That was the real issue. 

Hughes: What was the reaction in the room when you made that 
announc ement ? 

Silverman: Well, there was applause by these jokers in the towels. There 
were cheers and all that, which I wasn't looking for at all. 
Of course, what happens when you do something like that is 
there are a thousand questions. But, I just walked out. 

I conferred with the city attorney, and we talked about 
regulations. Now, that's when I called in this health 
director's medical advisory group, and we agreed to what the 
regulations would be, which was basically no sex between 
individuals. I then called the press conference later on April 
9 [1984]. 

Hughes: Yes, the regulations were proposed on April 9. 

Silverman: Yes. I didn't realize it was actually that fast. It seemed 
like it was longer. But then Wendy Nelder said, "Shameful 
delays in proposing sex guidelines." I guess the specific 
guidelines came later. 

Hughes: You proposed having regulations, but apparently it took a while 
to formulate them. 

Silverman: Yes. And then some members of the board of supervisors 

proposed transferring the bathhouse authority from the police 
department to the health department. Then they delayed and 
ultimately failed to give me the authority, and that was 
Britt's doing. 

Hughes: So the issue does go on a while. 

Silverman: Yes. And while that's going on there is a lot of debate. 

So then I called together that advisory group. Probably 
it was in late August, when I realized I had lost on the 
regulatory front, and I got a mixed response to the question of 
closing the baths. It wasn't unanimous at all from this 
committee. 



156 



Deciding to Close the Bathhouses 



Silverman: I remember walking out of the meeting and saying, "I've met 

with the community enough; I've met with advisors enough; I'm 
just going to make the decision and I'm going to follow 
through." And that night I said, "I'm going to close them." I 
knew what I had to do. I set about sending the inspectors in 
to the bathhouses. We sent them in; they came back; we looked 
at the reports; we spent a lot of time over at the city 
attorney's office seeing how we would proceed. And then I had 
that press conference which I guess was on October 9, closing 
all the bathhouses where unsafe sex occurred. We had inspected 
gay and straight bathhouses, so there wouldn't be 
discrimination. Then we did it [closed them]. 

Hughes: By the time you closed them, the virus had been isolated. Did 
that make your case easier? 

Silverman: At this point in time, I think I would have done it without 
that. But it certainly helped. Initially, with all this 
Feinstein pressure, we didn't even have the virus. 



Hughes : 



Hughes : 



The Mayor's Reaction 



Why were the bathhouses such an issue for Feinstein? 



Silverman: Well, I can tell you what the surface issue was, and then I can 
tell you what I think the real issue was. 



I want to hear both. 



Silverman: The surface issue was, you had a place where people went who 
practiced unsafe behavior. If you closed them down, you then 
saved lives. Simple, A equals B, B equals C, then A equals C. 



1 See Silverman' s declaration in support of a Temporary Restraining 
Order to close the bathhouses, Superior Court of the State of California, 
City and County of San Francisco, October 10, 1984. (Dean Echenberg 
papers, Bureau of Epidemiology and Communicable Disease Control, San 
Francisco Department of Public Health, drawer: Bathhouses, folder: 10-10- 
84 Declarations in Support, vol. 1.) See also: Press statement of Mervyn 
F. Silverman, October 9, 1984. (Same reference, folder: Sex 
clubs/bathhouse . ) 



157 



Hughes : 
Silverman: 
Hughes : 
Silverman: 

Hughes : 
Silverman: 
Hughes : 
Silverman: 



Feinstein had even said it: "If you can save just one life--." 
Well, my feeling was, if we pushed people out of those baths- - 
as they said, out of the baths and into the bushes --then we had 
absolutely no ability to reach them. Or, if we closed the 
bathhouses and they were reopened by the courts , then the 
impact that the health department could have would be minimized 
and more people would die. A little more abstract than, go to 
a bathhouse, get sick, and all that. 

If the mayor felt so strongly about saving lives, why 
would she have canceled this hearing we were going to have to 
set the necessary action into place? What I think is, she 
wanted me to clean up the city. It was abhorrent to her that 
these things [bathhouses] existed. Now, interestingly enough, 
not abhorrent enough to do something politically about it, 
because bathhouses were regulated already for sanitation; there 
was absolutely no regulation on sex clubs. None. We charged 
$300 to license a pretzel vendor, and yet sex clubs, which were 
making tons of money, were unlicensed. There was never a 
political move, and I think what she wanted me to do is to do 
it for her clean up the city. 

The mayor, unbeknownst to me, sent police inspectors into 
the bathhouses . 

Unbeknownst to you? 

Oh, yes. I had no knowledge of it. 

Why? 

She wanted to find out what was going on in the bathhouses. 
Then she showed me the report. 

But why would she have done that without consulting you? 
Because I guess she felt frustrated. I don't know. 
And she thought you might- - 

I don't know what she thought I might do, but she sent them in, 
and sent me the report, and I looked at it. There were a 
number of things that obviously indicated high risk behavior. 
There were a lot of things in there which had nothing to do 
with high risk behavior, but that were abhorrent to her. The 
interactions that took place in these locations were basically 
abhorrent to the mayor. I think sex is an issue for her. And 
especially this kind of blatant, raw sex. 



158 



Hughes: In her city. 

Silverman: In her city. You could see how upset she was about some of the 
things in the report. I'm sitting there thinking to myself, 
Yeah, there are some things that don't appeal to me, but they 
don't relate to AIDS necessarily. They related to this sort of 
crass sexual activity. 

Hughes: Well, it's an illustration of how personality enters into 
history. 

Silverman: Absolutely. She had a special feeling for the police 

department and ignored the existing regulations placing 
authority for the bathhouses under the police. So she was 
upset at any action she thought might involve them and when the 
time for action came near to the Democratic Convention, she 
didn't want any action at all. This doesn't sound like an 
overriding concern for health to me. 

Then the other problem is that Harry Britt was there [on 
the board of supervisors], and I think Harry was the most 
ineffectual supervisor we've had, and certainly ineffectual for 
the gay community. Oh, he was dancing from one side to the 
other, and he was against closing, and he was for closing- - 
whatever way the winds were blowing. [tape interruption] 



Leon McKusick's Studies 1 



Silverman: Then I found out through [Leon] McKusick's studies that the 
education activities were ineffectual. 2 When people were 



1 For a summary of McKusick's reasons for supporting bathhouse closure, 
see: Memo- -Bathhouses and Public Policy, Leon McKusick to Mervyn 
Silverman, April 3, 1984. (Dean Echenberg papers, Bureau of Epidemiology 
and Communicable Disease Control, San Francisco Department of Public 
Health, drawer: Bathhouses, folder: Sex clubs/bathhouse.) 

2 Leon McKusick, William Horstman, and Arthur Carfagni. Reactions to 
the AIDS epidemic in four groups of San Francisco gay men. Study conducted 
November 1983. A report prepared for the Department of Public Health, City 
and County of San Francisco, 1984. (Dean Echenberg papers, Bureau of 
Epidemiology and Communicable Disease Control, San Francisco Department of 
Public Health, drawer: Bathhouses, folder: 10-10-84 Declarations in 
Support, vol. 1.) 



159 



Hughes : 



Silverman: 



asked, "What do you know about AIDS?" there was a fairly good 
knowledge base. When they were asked, "Where did you learn 
about it?" it wasn't from the bathhouses. And also, people 
were reporting back that when they went into bathhouses and 
there might be a bowl of condoms, or there might be a poster. 
But when they went into the back room, there were the orgy 
rooms and the glory holes. I realized I was being lied to 
pretty much by the bathhouse owners. Some of the places they 
swore to me that they had closed up the glory holes , they 
obviously hadn't. 

So I wasn't getting the cooperation of the bathhouse 
owners. I had been informed that the parking lots reflected a 
real decrease in clientele but it started to increase again. 
See, business was bad and bathhouses were closing, so there 
wasn't as much of a push to close them. 1 mean, if they closed 
on their own, we would have accomplished what we wanted while 
maintaining the cooperation of the gay community. But when 1 
got the sense that business was starting to increase, along 
with the fact that I had tried everything else and had failed, 
that I had worked with the community long enough, that the 
community was educated now. . . I mean, they really knew the 
issues, as opposed to '83, when people were debating whether 
educational materials could even talk about safer sex. Then I 
thought, All right, I think we're at that point where we're 
just going to close the bathhouses. And we did it. And then 
they were reopened. 

Did you look upon the Larry Little John initiative as another 
thing pushing you to make a decision? 

Oh, no. That was the reason Conant got his group to sign on to 
back bathhouse closure by me. They were afraid that 
Little John's initiative would get on the ballot, and it would 
be voted in. Conant didn't tell me that in the phone call. 
The Littlejohn initiative didn't push me. The Littlejohn 
initiative pushed the leadership of the gay community to say, 
Silverman, not Littlejohn, should close the baths. Littlejohn 
really wasn't my issue. 



The Baths Reopen 



Silverman: After I closed the bathhouses, [San Francisco Superior Court 

Judge Roy L. ] Wonder came out saying, "The bathhouses can open, 



160 



but--" and then he put into effect all of the regulations 
concerning safer sex that I had tried to get in before. 1 

When Feinstein was questioned, she was just about 
ballistic that he had reopened the bathhouses. And when they 
asked me, I wasn't. Because, I said, "If there is no unsafe 
sex taking place, I don't care if they reopen." And I think 
that showed vividly what I knew all along, that the issue was 
the bathhouses and not AIDS. It was clear to me, if you don't 
spread the disease in there, then the bathhouses are not a 
health issue. 

Hughes: Had Wonder literally picked up your regulations? 
Silverman: I think almost word for word. 
Hughes: So you got what you wanted. 

Silverman: Yes. I think in fact there is a statement in one of the press 
articles that Silverman was vindicated. It demonstrated that, 
in fact, the bathhouses would have been reopened by the courts 
no matter when I closed them, but I don't think they would have 
been reopened, if I had closed them in '83, with that kind of 
regulation. If I had my 'druthers,' would I have done it that 
way again? Knowing what I know now, I'm not sure, but knowing 
what the situation then was, I think it was the proper way to 

go- 



Civil Liberties versus Public Health 



Hughes: You couched your arguments for keeping the baths open in terms 
of AIDS education and cooperation with the gay community. I'm 
wondering to what degree you also saw the issue as one 
involving civil liberties as opposed to public health issues? 

Silverman: Well, I have been criticized, along with a number of other 
public health people, of being more concerned about civil 
liberties than public health. My feeling has always been that 
when public health and civil liberties come into conflict, 



1 See Modified Preliminary Injunction, signed by Judge Wonder, December 
21, 1984. (Dean Echenberg papers, Bureau of Epidemiology and Communicable 
Disease Control, San Francisco Department of Public Health, drawer: 
Bathhouses, folder: Sex clubs/bathhouse.) 



161 



public health wins. During a smallpox epidemic, you don't 
worry about confining people; you do it. 

However, with AIDS, civil liberties and public health are 
consonant. I did not see the bathhouses as a civil liberties 
issue. There are certain places where things are allowed, and 
certain places where they're not. You can't have sex at 
McDonald's. You generally cannot have sex in the pews of a 
church or in a synagogue. People don't feel their civil 
liberties or civil rights are being in any way abrogated 
because of that. So I don't think the reasoning was really 
civil liberties. 

I think where the civil liberties issue came in, and where 
I'm sure it had some effect, if people saw government closing 
the bathhouses, the issue would become civil liberties, civil 
rights, homophobia, whatever, and not AIDS. And what I was 
trying to do was keep it AIDS. 

Now, as I said, until I closed them down, I was trying to 
work with the community to have a behavior change that spanned 
the whole community, not just the bathhouses. When I closed 
them down, I made it very clear that this did not in any way 
take away from civil liberties; all it did was say, "In certain 
situations, certain behaviors are not allowed," and we do that 
throughout our daily lives. You can not drive fifty miles an 
hour down the street. You can not stand out in the street and 
yell at three o'clock in the morning. What we were saying is 
that commercial establishments like the bathhouses can't allow 
penetrative sex. 

Hughes: And yet, elements of the gay community were putting the 
bathhouse issue forward as a civil liberties issue. 1 

Silverman: Oh, most certainly, throughout the entire episode, and 

afterwards. And what I said is, "In your bedroom, you have the 
right to do whatever it is you want. When you have commercial 
establishments that foster the spread of a disease that is 
lethal, especially at the same time that the city is being 
asked and even demanded by the very same constituency who might 
frequent such places to do something with regard to education 
and care, there seems to be a real paradox." To have these 



1 See, for example: Press statement of civil rights and lesbian and 
gay community organizations. October 10, 1984. (Dean Echenberg papers, 
Bureau of Epidemiology and Communicable Disease Control, San Francisco 
Department of Public Health, drawer: Bathhouses, folder: Sex 
clubs/bathhouse . ) 



162 



clubs operating- -some of them with no Inspection and no 
regulations --to me didn't make a lot of sense. 

Hughes: Did the actions you took in the bathhouse episode extend the 
powers of health department? 

Silverman: The powers of the health officer in most cities and counties in 
the United States are incredibly extensive. They are far- 
reaching. Now, you can't be capricious; if you are, you could 
be held personally liable. I kept a part of the financial 
district [of San Francisco] closed for several days, even 
though the fire department and police department thought they 
could open it up, because PCBs had been spilled as a result of 
a transformer explosion. I could close City Hall. I could 
close any police station, any restaurant. I could close your 
house down; I could evict you from your house. I really in a 
sense had almost more power than the police have. So 1 always 
dealt with that power very judiciously. 

In answer to your question, in one sense, yes, it did 
extend the power, because I don't think there had been a 
situation where a place was closed for public health reasons 
solely because of activities that were taking place rather than 
because of raw sewage, contaminated air circulating- -what have 
you. So this was a legal departure, but certainly I don't 
think it was any departure at all from the powers invested in 
the health officer. 

Hughes: Did you enforce public health policy differently in the AIDS 
epidemic than in other epidemics? 

Silverman: In a sense yes. People have said, "Why are you treating AIDS 
differently than other diseases?" With other diseases we have 
testing and reporting, and we don't place such emphasis on 
maintaining absolute confidentiality and protecting people's 
civil rights. Why is AIDS different? I think because of 
discrimination, we have to do things differently with AIDS than 
we might do with, say, polio. It created, and still creates 
today as we speak, incredible barriers and reactions by others 
to people with HIV, people who have AIDS, people who care for 
them, and people who are family members. 

So we do things differently, because it is a different 
epidemic. It is not like others. The virus behaves like many 
other organisms, in a sense. But the way in which society 
behaves is totally different, and therefore the epidemic has to 
be dealt with differently. 



163 



Assessing the Decision Regarding Closure 



Silverman: I look at public health like a physician should look at the 
human body. The community is the organism, if you will, the 
human being. If you have a heart problem, I wouldn't want to 
give you heart medicine that destroyed your liver. So even 
though this drug works for your heart, it's almost like "the 
surgery was a success but the patient died." In your zeal to 
cure one problem you don't want to create an even bigger one. 

If bathhouses were the only place that people were being 
infected, closing them wouldn't have been an issue. It was 
very clear that 90 percent of the gay community was having the 
same kind of sex, maybe with fewer people, maybe a little 
variation on the theme, but from everything I heard, it was 
risky behavior. Anal intercourse is risky behavior. That was 
the predominant mode of sexual activity. We weren't sure at 
that time where oral sex placed on a risk scale. I didn't want 
to politically solve this problem while a bigger cancer was 
growing, and that bigger cancer was the unsafe sexual behavior 
throughout the community. 

Dean Echenberg, who was my communicable disease person, 
took over after Dritz as head of the health department's Bureau 
of Communicable Disease Control. He is convinced that the rate 
of rectal gonorrhea dropped about 85 percent- -not down to 85 
percent; dropped 85 percent from about late 1981, early '82, 
until the time I left [December 1984] , and then it even dropped 
further. We used as a surrogate marker the rate of rectal 
gonorrhea, which obviously is a very good marker for homosexual 
activity. He is convinced that it was because of the messages 
I was putting out there, along with seeing the impact of this 
disease. I mean, you can't get away from that. 

Our city clinic, which was basically a STD clinic for gay 
men, was packed solid when I went to visit it as the new 
director of health. When I went back there in '83 or so, you 
could hear a pin drop. The place was literally empty. Not 
because people were going somewhere else. The rectal gonorrhea 
rate had dropped dramatically. 

Hughes: So the message was getting through. 

Silverman: The message was getting through. My biggest fear was that if 
people didn't see the health department as a partner in their 
health care, but rather saw it as the policeman, which is what 
would have happened if I closed the bathhouses and they 



164 



reopened in the early eighties, we wouldn't have been the force 
that I think we were able to be. 

That point does come out in Cities on a Hill. 1 I think 
the author captures that, and that's really where I was at. 
Now, I can't say that I was clear of mind all the time. This 
[the bathhouse issue] was one of the most difficult things that 
I've ever dealt with, and the problem was compounded because 
there was nobody there to help me. Feinstein was saying, "It's 
very obvious." I said, "If it's so damn obvious, why am I the 
only health director considering bathhouse closure? None of my 
colleagues are considering it anywhere in the country." 

Hughes: You were talking with them? 

Silverman: Oh, yes. I became president of the U.S. Conference of Local 

Health Officers in 1984. So I looked on the surveillance list 
for AIDS, and took the top ten cities, called their health 
officers and said, "Let's have a meeting. I want to meet with 
all of you guys and gals. Let's get together." I said, "And 
bring your educational materials." 

We got together. I walked in the room, and what do I see 
but our education materials with their name on it, and everyone 
looking at me. [laughter] And so if it was such an obvious 
public health answer, then why was I the only one being asked 
the question? To this day, there are public health officers 
that don't want to see bathhouses closed in their communities. 

Now, my position today is that unless there is only 
masturbation going on, mutual or single, whatever, in a 
bathhouse, that I can't condone their opening. Now someone 
would say, "Gee, that doesn't sound the way you sounded 
before." Well, we're at a different point. Everyone knows the 
issues. Bathhouses no longer are the symbol of gay liberation. 

And that's why I purposely used in my statement, 
"Bathhouses aren't a symbol of liberation, they're a symbol of 
death." I chose my terms carefully. This was the place where 
you could go quietly from your "straight" public existence, 
have sex, protectedno cop was going to hassle you, and nobody 
was going to bash you- -and then walk back out and you were in 
the straight community again. Yes, initially the bathhouses 
were a symbol. 



J Frances FitzGerald. Cities on a Hill: A Journey through Contemporary 
American Cultures. New York: Simon and Schuster, 1986. 



165 



Hughes: Well, it's an important point. I think one of the reasons why 
the epidemic was handled differently in this city as opposed 
to, say, New York, was the cohesion of the gay community. It 
was an organized political force. It had created a place where 
gays could be themselves, and then the epidemic hit. The 
information I've gotten is that the gay community in New York 
was not as cohesive. 

Silverman: Yes, and New York just being New York. 
Hughes: Exactly, there were so many other issues. 

Silverman: And there was a lot of fighting within the gay community, and 
there still is, because the gay community is not monolithic. 
There is every color and stripe. 

But we had many things going for us that other communities 
didn't. We had a caring community, gay and straight. We had a 
supportive executive and legislative branch, we happened to 
have a budget surplus, and we were talking about a disease of 
gay men primarily, not of drug users. That's a much different 
community to deal with, whether you're talking about services 
in clinics or services on the wards. When the wards at San 
Francisco General started getting some drug addicts, some staff 
started leaving who had stayed longer than anyone would have 
believed under the emotional pressure. The gay man was very 
appreciative of what was being done, supportive, and followed 
what was being asked of him. 



Resigning as Health Director 



Hughes: Let me ask a final question on the bathhouse issue: you 
resigned in December, 1984. 

Silverman: Effective January 15. That's the date that the commission 
began. 

Hughes: Well, explain that, please. 

Silverman: There was a move, an initiative, to separate the health 

department from the CAO and put it under a health commission- - 

Hughes: What's the CAO? 

Silverman: The chief administrative officer- -Roger Boas, at that time. I 
worked for Roger Boas; I knew that whether or not this passed, 



166 



I'd be out of a job. (Boas would try to get rid of me for 
supporting the health department's removal from his office and, 
for reasons I will explain, Dlanne would want me to leave.) 
But I went out and supported It. The reason I did Is because 
the health department Is much bigger than I am. You see, the 
way the system was, if you had a problem with the health 
department or health situations in the city, you had only one 
person to go to after the health director and that was the CAO, 
and if he or she didn't want to listen to you, that was it! 
And I thought the health department was too much of a community 
organization not to have real community Input. I thought a 
health commission was important. 

Now, the minute it became a health commission, the health 
department would be under the mayor. That would put me under 
the mayor. And I was aware, because of Dianne's and my 
differences on this bathhouse issue, plus her lack of support 
for me when I had some other problems at the hospital early on, 
that that was probably going to mean I'd be out of a job. 

So when it passed, as I say which I supported, I went to 
meet with the mayor, and It was very clear she wanted her own 
health director. It was a mutual 'splitting of the blanket.' 
She kept me on as a full-time consultant for three months, and 
then it was going to be as a half-time consultant for the next 
three months. I think I brought in over a million dollars to 
the city. I was the reason why we have anonymous testing sites 
around the country. Another interesting story which may not be 
of any import here. 

They were actually asking me to stay on full-time, and I 
wouldn't do it. On a half -time basis I was still getting 
dinged by [San Francisco Supervisor] Quentin Kopp over things, 
and I figured, What do I need this for? So I actually could 
have stayed on, but at the end of the six months, I just left 
totally. 

If the situation were different, I probably would have 
stayed on as health director, but when you don't have the 
mayor's support behind you, that's a very vulnerable position. 
I've said often that I was happy and challenged- -I loved my 
job, and people thought I was crazy, with all the controversy 
here. But I didn't mind trying to slay the dragons out there 
as long as I had somebody behind me. Well, when you lose that 
backing, and I realized that I had lost it with Feinstein, then 
you're in a very untenable situation. You have to constantly 
cover your flanks . 

Hughes: That period must not have been fun. 



167 



Silverman: 

Hughes : 
Silverman: 

Hughes : 
Silverman: 



Hughes : 
Silverman: 



It really wasn't. It was very, very difficult. A lot of the 
difficulty was wondering if I was doing the right thing. There 
were a lot of sleepless nights. 



I heard that you lost weight during this period, 
indeed true? 



Is that 



I could have used the weight loss, but I don't think I did. I 
think I probably showed the strain in my face. 

It took a physical toll. 

Yes. People see me as fairly ebullient, and I don't think I 
probably was very ebullient during that time. I certainly 
didn't want to do things that were going to result in more 
death and dying, whether it was from not making a decision or 
making a decision. It wasn't terribly clear all the time that 
the way I was going was necessarily the best, even in my own 
mind. But I didn't want the unsafe behavior continuing in 
bathhouses. It was very clear that they needed to be closed. 
It was how to do it in a way that didn't cause more problem 
rather than less, and that was where the dilemma was, not 
whether they should be closed. 

There are still some people out there upset that I closed 
them, but I don't think very many. However, I don't think 
there's anyone out there who thought I was homophobic, that I 
was doing it for that reason. I think all of them, even if 
they were on the other side of the issue, realized that it was 
something that I was grappling with. I can live with myself. 

As I say, I've thought long and hard, would I do it 
exactly the same way? In general, yes. Knowing what I know 
now, I probably would do some things differently, but I 
wouldn't close the bathhouses immediately. I certainly 
wouldn't hold that press conference, either. And I might deal 
with the gay community in different ways, to try to further 
encourage them, maybe give them an ultimatum: "Well, listen, 
guys, I'll give you to this day, and if I don't get support 
from you, then I'm going to take action," statements like that. 

So no regrets in terms of this episode? 

No. I'm glad I went through it. As I may have mentioned to 
you before, I would do it all over again, but I wouldn't do it 
again. 



Hughes: 



[laughs] Yes, you did say that. 



168 



Silverman: It was an incredible period; it was an exciting period; it was 
challenging. There are a lot of health officers who haven't 
experienced it and won't, and I don't think they're better for 
it even though it saved themselves the aggravation. Not me. I 
think it was a very, very challenging time. 

When it became a problem is when I no longer had any 
political support. Then that was untenable. 

Hughes: Did you feel betrayed at that juncture? 

Silverman: Oh, yes, I think to some extent. But you see, I had expected 
it. 

I* 

Silverman: The mayor was somebody that I would have obviously gone to bat 
for- -I mean, I may in the back room have said, "What the hell 
is going on?" but I was going to bat for her, and she didn't 
have the courtesy to pick up the phone and say, "Merv, what's 
your side on this issue?" 

She took potshots at me when she was in Washington in a 
limousine with a political reporter, which is in Randy's book, 
saying, "Why didn't Silverman have the guts to close the 
bathhouses; if it related to heterosexuals, he would have 
closed them." Which was true: heterosexuals didn't have the 
bathhouse issue as a symbol. 

Feinstein got wind of the fact that I was upset about her 
position on the hospital problem I mentioned before, and I 
remember after one of our general meetings of department heads 
she called me into her little private room and said, "I hear 
you're upset with me." I said, "Absolutely." She said, "Why?" 
I said, "Because you didn't even pick up the phone to call me. 
We've worked together all this time, I was with you in this 
city and that city, we traveled together, I've always supported 
you." A lot of people thought I was crazy, especially the gay 
community. Many didn't like her. And I was arguing in her 
favor . 

She said, "Well, you work for Roger Boas." And I said, 
"What are you talking about? You and I are on the phone every 
day. I don't talk to him for weeks. You and I sat up all 
night working on the strike at San Francisco General; he was at 
home sleeping. We've had a relationship." She sort of danced 
around. So she was really doing a number on me. 

Hughes: Was it in an attempt to distance herself from the whole issue? 



169 



Silverman: Well, no. It was to be on the "right side" of the issue 



Silver-man's Recent Positions 



Hughes: You went straight to AmFAR [American Foundation for AIDS 
Research] after resigning as health director? 

Silverman: No. Interestingly enough, I went with AMI [American Medical 

International], which was a for-profit hospital corporation. I 
was going to become their spokesperson, a very lucrative thing 
for me. We were going to have our own TV studio, and I was 
going to be their point person. Then their profits started 
going down, and they decided to eliminate the whole concept. I 
worked with them for about seven months, and I was also doing 
some consulting in Africa, family planning. 

January of '86, I came on with AmFAR half-time, and about 
the same time went on half-time with the Robert Wood Johnson 
Foundation as director of the AIDS Health Services Program. 
I've been doing nothing but AIDS since then, except one 
consultation, which has ended, in Santa Clara County dealing 
with the reorganization of their health system. 

Hughes: Is that all right that you're focused fully on AIDS? 

Silverman: Probably not all right for an ultimate career kind of thing, 

because you get typecast. But certainly all right because it's 
so challenging, and it's something that I think I can 
contribute to. I have absolutely no regrets about any of this, 
including leaving the health department. I was planning to do 
it when I turned fifty. 

Hughes: To leave the directorship of the health department? 

Silverman: To get into some corporate situation in order to make some 
money so I'd have something for retirement. I'd been in 
federal and city government; I hadn't really developed any 
retirement fund. I was getting a little antsy about that. 
Also, people had told me when I first came to San Francisco, 
"Don't stay in the health department longer than five years. 
You really ought to get out." 

Hughes: Because that's typecasting too? 

Silverman: No, Just that it starts turning against you. If you look at 
most positions, it doesn't matter what department you're in, 



170 



that happens. Whether you're the mayor or whatever the 
position is, there's a time frame. Now, I'm glad I didn't 
listen to them, because the AIDS epidemic occurred in the last 
part of my term, two and a half years beyond the five. 

[Interview 3: July 6, 1993] ## 

Hughes: You were quoted in the book AIDS and Patient Management, in 
which you had a chapter called "Addressing Public Health 
Concerns in the City of San Francisco," as saying, "The 
screening test is a good screening test for blood. It is not a 
good test for people." Would you like to amplify on that? 

Silverman: Well, at that time [1986], we couldn't do too much with the 
test. The results of the test didn't change your treatment 
schedule, because there was none at that time. Obviously, if 
you were donating blood, the blood should be tested. But 
testing people did not make any sense at that time. I 
initially was a little reluctant to encourage testing, because 
the message would be the same. In other words, if you're 
negative, stay negative, and here's how to do it. If you're 
positive, don't get reinfected and don't infect others. Here's 
how to do it. The message was basically the same. 

An individual from Australia heard me say that, and he 
said, "I think you're selling the community short. I think 
there's much more that can be done. Certainly there is the 
impact of the testing on the message that you give. If a test 
is positive, it can be a powerful factor in motivating behavior 
change." And I reevaluated what I was thinking about, and 
really within months encouraged people to take the test. 

I guess what I was saying here is, they're testing people 
in the military. They're testing people for insurance. It's 
not part of a diagnostic workup; it's not part of a treatment 
plan. 

Hughes: It's the social implications. 

Silverman: It's the social implications. I was encouraging people to get 
tested through anonymous testing sites. I reevaluated my 
position probably over thirty days from the time the test was 
available. I realized that when someone is a smoker, you can 
take their chest x-ray and put it up on the light box and say, 
"Look at your chest. If you keep smoking, I don't know what 
I'm going to do." Now, the chest x-ray may be negative, but to 
the untrained it always looks strange. The point is that the 
x-ray film serves as a further reinforcement for the message 
you're trying to give. 



171 



Testing Advocate 



Silverman: As I reviewed my position, it seemed that taking the antibody 

test was not a bad idea. Again, I wanted it done in a way that 
would not come back to haunt anybody from the social side. I 
became a real advocate of testing, I'd say, from April or May 
of '85. 

Hughes: One other use of the test, before early drug intervention was 

possible, was to inform people that they were HIV-positive, and 
discourage further transmission. 

Silverman: Well, that's what I said. You should be counseling somebody 
who's engaged in high-risk behavior that, regardless of what 
the test result is, you should not be having unprotected sex. 
If you're positive, I don't want you to be reinfected; I don't 
want you to infect others, so properly use condoms. If you're 
negative, I don't want you to get infected, so use condoms 
properly. Therefore, the message really was the same 
regardless of the test result. 

Incredibly, early studies showed that people who learned 
they were HIV-negative ended up having more unsafe acts than 
people who were HIV-positive. 

Hughes: Yes, that was one of the arguments. 

Silverman: Believe me, I don't want to try to get into the psyche of the 
gay mind, but there was the idea, "If I'm positive, I don't 
want to hurt you. If I'm negative, if I get it, I get it." 
Self hate. There are a lot of issues that people go through 
who come to grips with their homosexuality. So it was almost a 
sense of altruism on the part of the positive, and a sense of 
who knows what on the part of the negative. 

Hughes: Well, that sort of argument was used by some of the blood 
bankers when the HIV antibody test was developed. Their 
argument was that if a member of a high-risk group did indeed 
test negative, and the validity of the test was not at all 
ascertained, that this might encourage promiscuity and unsafe 
sex practices. 

Silverman: Well, I don't know if it would encourage promiscuity, but it 
might encourage you to continue your behavior, whatever it is. 
The questions asked before donating blood should eliminate you: 
"Have you engaged in A, B, C, D, E? If you have, we'll chuck 
your blood." However, one could argue that the markers could 



172 



be there for someone who didn't believe they were at risk, and 
so it might help. 



Blood Screening 



Silver-man: I think there was probably a sense of fear of losing a lot of 
the donated blood supply because a lot of donors were gay men. 

Hughes: Oh, there was that fear. 

Silverman: I was upset at some meetings, international meetings and such, 
where blood bank people were more concerned about maintaining 
the volume of the blood supply and obviously they should be 
concerned about the supply of blood- -than they were about the 
risks to people who might be getting that blood. 

Hughes: I have read that the blood bankers felt very strongly that they 
had the prime responsibility of preserving the volume of blood 
donation, that it was much more harmful to society to not have 
a unit available when somebody really needed it than to run 
what they considered to be a rather slight risk of transfusion 
AIDS. 

Silverman: And I think that's true if physicians use blood only in life- 
threatening situations. If there's anything good that has come 
of this horrible epidemic, it is a rethinking of when blood 
should be transfused. It used to be if you came out of surgery 
and you looked a little weak, they might give you a unit of 
blood to perk you up. Now that's changed for the good. 



Setting Up Anonymous Testing Sites 



Silverman: As president of the U.S. Conference of Local Health Officers 
[1984], I had written a letter to [Secretary of Health and 
Human Services Margaret] Heckler, because the HIV antibody test 
looked like it would be approved soon. There was no interest, 
it seemed, in setting up anonymous testing sites, and from the 
few surveys that we made here, it was very clear that many gay 
men would be going to the blood bank- -this was before the fear 



173 



of discrimination resulting from taking the test to find out 
whether they were infected or not. 

I wrote a letter to Heckler basically saying, "We've got 
to set up outside testing centers, anonymous testing sites, so 
that we don't actually further contaminate the blood supply by 
encouraging gay men to donate blood in order to be tested. If 
I don't get some response in a couple of weeks, I'm going to 
have to go public with this thing." 

I didn't get any response in two weeks, so we put out a 
press release, which I didn't realize was going to be seen by 
HHS before the press conference. The Public Health 
Association, APHA, was going to be co- sponsor of this thing. ] 
didn't know that my press statement was issued on Wednesday 
night --this was going to be a Thursday press conference 
release. 

All of a sudden I get this call from Frank Young, the 
commissioner of FDA [Food and Drug Administration], and 
Heckler's special assistant, who I think was sent to jail for 
something he was doing in the department. My press statement 
was a warning to the nation that its blood supply could be 
contaminated if alternative testing sites were not set up. 
Young and Heckler's special assistant said, "How can you say 
this?" I said, "Because I believe it." At that time, we 
didn't know how accurate the antibody test was, because it was 
information kept secret by the company [Abbott]. We didn't 
know how many false negatives, false positives the test 
produced. Well, to make a long story short, by the end of the 
call, I had $12 million, and they set up anonymous testing 
sites around the country. 



The Epidemic's Impact on Medicine 



The Doctor-Patient Relationship 



Hughes: Do you have ideas about what effect the epidemic has had on 
medical practice? 

Silverman: Yes, there are several. One, the issue of blood supply. Two, 
changing some of the very sloppy techniques that we had in 
clinics and hospitals and emergency rooms, dealing with body 
fluids and needles and sharps of all kinds. Three, it's 
certainly changed the doctor-patient relationship in a very 



174 



positive sense. Merle Sande from San Francisco, who is chair 
of an NIH advisory panel, said in the paper over the last week, 
"If you're going to use AZT, that should be discussed with the 
patient and the decision jointly arrived at." 1 Historically, 
medicine has been top down. The decision is arrived at by the 
physician, and he or she tells you what it is. 

Hughes: Isn't that a result of the ambiguity of science at the moment, 
the fact that It isn't clear that early drug intervention in 
AIDS Is beneficial? 

Sllverman: Yes, but it wasn't clear several years ago. 

I have always believed that there ought to be a 
partnership in medicine, and I was preaching that long before 
AIDS. I think it would reduce malpractice suits, because you 
don't generally sue your partner. But If a stand-offish 
physician tells you what you should do, and It doesn't work, 
then [the patient] may be upset and sue. So that's a non- 
altruistic reason for physicians to form a partnership with 
their patients. 

I also believe that patients do better when they're part 
of their therapy. It became a reality with AIDS, at least with 
physicians in this community and some of the other communities. 
It's also allowed physicians to break out of their very stiff 
mold and think of alternative therapies, which before the 
epidemic they would have totally discarded out of hand. 
Physicians, many of whom were gay men themselves, were 
frustrated and realized that they didn't have much to offer to 
patients, decided, why not, let's do it [alternative therapy]. 
But maybe you should let me supervise your health care while 
you're doing whatever It is you're doing. I think that's also 
a potential plus. 

The whole program of the Robert Wood Johnson Foundation, 
utilizing the San Francisco model, is a plus because it 
certainly can be used In any chronic situation, whether it's 
cancer or Alzheimer's or whatever- -the idea of case managing or 
care coordinating with the patient, generally trying to 
emphasize out-of-hospital care when It's appropriate. So It 
doesn't have to be utilized only with AIDS. What we did in a 
number of cities throughout the country was bring people to the 
table who hadn't been there before. Eventually you get some 
coordination and collaboration which also hadn't happened 



1 Lawrence K. Altman. Government panel on HIV finds the prospect for 
treatment bleak. New York Times, June 29, 1993, C3. 



175 



before. So the process is another positive impact of the 
epidemic. 

Hughes: It seems to me another voice in this movement has been the 

patient himself, herself. I'm thinking particularly of the gay 
community, which is, speaking in generalities, an informed, 
intelligent group, which when this epidemic struck set about to 
become informed about AIDS. In some cases, patients perhaps 
went with more knowledge to a physician than the physician 
himself had. 

Silverman: Not perhaps; in most cases. That's definitely true. 

Women with breast cancer and other cancer patients are 
looking at AIDS activism and saying, "Why aren't we doing the 
same thing?" Of course the difference is just what you said, 
gays had a community before they were affected, whereas the 
cancer community is-- 

Hughes: Too dispersed. 

Silverman: Very. That kind of activism has mixed blessings, and I have 

some real problems with some of it, but some of it has had very 
positive effects. All the things that I've mentioned are a 
plus to medicine and a plus to the patient. There may be more, 
but none others come to mind. 



Accelerated Drug Approval 



Hughes: Well, I can think of one which is related to AmFAR, and that's 
the transformation of the drug approval process. 

II 

Silverman: The positive aspects of it are the streamlining of activities 
at FDA and the appointment of community people to what 
previously were very much pure scientific review or advisory 
boards at NIH. Activists said, "If you're going to be studying 
me, I want to have a say. I may not be able to tell you the 
microbiology, but I can certainly tell you what it means to me, 
what the impact of doing this or doing that may be." 

It's like Los Angeles County General Hospital, where I did 
my internship, showing us the formulary. And then they showed 
us what the cost of each of those drugs in the formulary was 
and also the costs of the tests that you were doing on 



176 



patients--! guess It was the tests even more than the 
formulary- -so that you would have an understanding when you 
ordered that test what the financial Impact was going to be. 
At that time, there wasn't a lot of health Insurance. So when 
you told the patient, "You need this test," he had to reach in 
his pocket for $100 or $200. Physicians ought to know those 
costs and factor that aspect into the decision making. 

That's the reverse of having consumers on these boards to 
tell them what the impact of medical decisions is. Well, for 
example, if it means I have to be hooked up to a machine in the 
hospital; that means I can't go to work. Which might change 
the system so that we have in-home infusions. That's another 
impact of the AIDS epidemic- -more emphasis on care in the home. 
There are a lot of things that people are doing on an 
outpatient basis that before were inpatient, and a lot of 
things done in the home that probably would not have been 
allowed in the past. 

Hughes: There also has been a change in the standards by which the FDA 
had previously judged a drug. The fact that you are dealing 
with a lethal disease for which there is as yet no really 
effective treatment gives a different dimension to how you 
think about safety and efficacy. 

Silverman: Well, it doesn't change safety too much. It does change 

efficacy. Generally drugs are not released until phase II 
efficacy trials. I was asked to testify before a committee 
advising the Food and Drug Administration, and one of the 
people on the panel had been the counsel to the FDA when I was 
there, Peter Barton Hutt. 1 He asked me, "Are you really 
saying that once a drug has been shown to be relatively safe, 
that people should have access to it?" And I said, "Yes. When 
you and I were both with FDA, I probably wouldn't have said 
that. But now, knowing what I know and what I've seen, I would 
have to support some type of distribution- -it certainly 
wouldn't be putting the drug in the pharmacies- -that allows 
people who have no therapeutic alternative to have a chance at 
it." 

When people say, "I should be able to take any drug no 
matter what," I don't know that government can sanction that. 
Those people say, "I don't have an alternative. I'm going to 
die." Yet, they do have an alternative, and that is when 
they're going to die. So I think it's important that we still 



: Dr. Silverman was special assistant to the FDA commissioner, 1969- 
1970, and director of the FDA Office of Consumer Affairs, 1970-1972. 



177 



have certain safeguards. There obviously were people who died 
of PCP the day before a drug that could treat PCP became 
available. And they may have died the day before because they 
took something that was counterproductive. So I think we have 
to be sure we don't do more harm than good by accelerating drug 
approval . 



San Francisco Model of AIDS Care 
Definition 

Hughes: What does the San Francisco model entail? 

Silverman: Well, first, let me make it clear: we never set out to 
establish a model. Most of it was reactive; some was 
proactive. The model was a care system, basically a case- 
managed continuum of care with emphasis on outpatient services. 
And this is how it grew: we had the AIDS clinic. As it became 
crowded we set up testing sites in the community, and then we 
needed to take care of people who required inpatient care so we 
created the dedicated inpatient unit. Then we had to address 
the question of what do you do with the patient who no longer 
needs acute care but has nowhere to go? We then looked into 
emergency housing, long-term housing, hospice care, support 
care, buddy systems, all these things. What was becoming very, 
very clear here and everywhere else was that what was making 
the length of hospital stay so long wasn't the actual condition 
of the patient, the acuity. It was the fact that there was no 
place for this person to go. He didn't need acute care, but he 
needed care, and there was no one in the home to provide it, 
and a number of other situations. 

Because San Francisco is unique and because the health 
department provides an umbrella of health services, there was a 
much greater ability to look outside to the community, to bring 
people together, to say, "Okay, let's get the Visiting Nurses 
Association to help; let's see about hospice; let's get the 
mental health people involved and some support groups; let's 
get the gay community to contribute." Most of the pieces exist 
in most communities. They just don't seem to talk to each 
other very often. 

And this should not be unique to AIDS. Any chronic health 
care condition can benefit from this kind of "model." 
Unfortunately, case management has a different definition 



178 



everywhere you go. Sadly, some insurance companies are using 
case management primarily to manage the case in order to keep 
the cost down. We were managing the case, or better put, 
coordinating the care so that the individual got the best care, 
the most appropriate care. That ended up being an economic 
benefit to the community. But our purpose wasn't to save 
dollars, it was to provide the most appropriate care that was 
needed. 



Transfer of the Concept 

Hughes: I'm wondering in your experience how transferrable the San 
Francisco model indeed has proven to be. 

Silverman: The concept is transferrable, although it need not necessarily 
be a Xerox copy of San Francisco's program. The concept is 
based on getting people who can provide some service around the 
table, and getting them to reach a consensus on what needs to 
be done. That service could be through the media, through 
education or information, through private doctors, private 
hospitals, public hospitals, public health, visiting nurses, 
hospice. I cannot believe this model is not transferrable 
almost everywhere. 

Now, you may not have a visiting nurses association in 
Houston, and in Dallas you may not have a hospice, and in 
Detroit or Chicago you may not have housing or 'what have you' 
already available. But the concept is transferrable. The 
exact image might vary, and it did. In the eleven cities in 
which the Johnson Foundation developed health care delivery 
demonstration projects for people with AIDS, there were no two 
alike. [tape interruption] 

It's obvious: New York City is totally different from San 
Francisco. To say, "You ought to do what we did in San 
Francisco, and if you do, you'll have the same results," is 
nonsense. In San Francisco, we had a supportive board of 
supervisors, a supportive mayor, a budget surplus; the cases 
were almost all in gay men, not drug users. So the way in 
which all the aspects of the model apply change totally when 
you go to where there's drug use, political differences, and 
financial distress almost all the time. So it makes New York 
look entirely different. The consensus that you get in New 
York may be by neighborhood rather than city-wide. But the 
concept of trying to bring people together to solve problems 



179 



that ultimately affect them, either in the delivery of services 
or what have you, makes sense. 



Robert Wood Johnson AIDS Health Services Program 



Hughes: Were just eleven cities interested in the San Francisco model? 

Silver-man: No. There were I think about 100 eligible cities. The 

criteria for selection had to do with the number of AIDS cases. 
The Robert Wood Johnson Foundation did site visits on twenty- 
five. The amount of money available was limited to nine 
programs, but two of them were double sites. In other words, 
there were Miami and Ft. Lauderdale , or Dade and Broward 
Counties, and in New Jersey, Jersey City and Newark. So we 
funded nine programs, but that meant eleven sites, and the only 
magic was the availability of funds. It was a $19 million 
program, going to nine programs serving eleven cities for three 
years . 

Hughes: How was the program implemented? 

Silverman: Well, Paul Jelinek of Robert Wood Johnson, who's now one of the 
vice presidents, and Drew Altman, who's now head of the Kaiser 
Family Foundation, were impressed with what they saw here. 
They came out and talked with Phil Lee and myself, and then 
invited me to come back and interview and see if I would be 
willing to help them do the final planning and then implement 
it, which I did. The program actually was housed at UC at the 
Institute for Health Policy Studies that was directed by Phil 
Lee. He's now Assistant Secretary for Health, as you know. 

The decision was that numbers of cases would be the 
determining factor. So we put out an RFP, request for 
proposal, to the 100 cities. I think almost all of them 
applied. We did a review to eliminate those that just really 
didn't look like they could do it, for whatever reason, and 
then settled on twenty-five cities, realizing that we would 
probably only be able to fund ten to fifteen, depending on how 
much funding would be needed in each community. New York 
required more funding because of the complexity, and so we 
ended up funding nine programs. They were New York City, Long 
Island, Miami and Ft. Lauderdale --Dade and Broward Counties--, 
New Orleans, Atlanta, Seattle, Palm Beach County, which was 
where there was a big brouhaha over the mosquito theory of 
transmission of AIDS, Newark and Jersey City, New Jersey, and 
Dallas. So that was the nine programs affecting eleven cities. 



180 



What also made them not carbon copies was that only one of 
the programs was out of the local health department. One was 
part of the Catholic charities in New Orleans. One in Palm 
Beach County started with a hospice for other conditions. 
Jackson Memorial Hospital in Miami received the funds for Miami 
and Ft. Lauderdale. In Atlanta, it was a community-based 
organization, Aid Atlanta. In Dallas, it was a community 
consortium already formed for other purposes. In Seattle, it 
was the health department. On Long Island, it was the county- 
based group. In New York it was a joint arrangement between 
the AIDS Institute and New York City. In New Jersey it was the 
state health department. 

Hughes: Why these particular institutions? 

Silverman: That's who applied. I was upset initially that more health 
departments hadn't applied, but afterwards was glad more 
didn't, because they were much more resistant to community 
involvement, and that really bothered me. San Francisco and 
Los Angeles applied, and did not get it. 

Hughes: Why not San Francisco? 

Silverman: Well, basically, it was a very poor proposal. I think it was 

also due to a sense on their part that they were a shoo-in. In 
fact, Dave Werdegar wouldn't talk to me for six months after 
that. I remember saying to him, "I'm sorry you all didn't get 
it, but of course you understand that Phil and I had to absent 
ourselves from the process." And instead of saying, "Oh, yes, 
of course," there was no answer. And I think he was angry that 
Phil and I didn't do something to assure San Francisco would be 
chosen. In fact, San Francisco had a second crack at it at a 
site visit, and still didn't get chosen. And Los Angeles I 
figured would be a shoo-in also, and it was not. 

Hughes: Again, because of a poor proposal? 

Silverman: I think basically yes. I don't remember the exact reason, 
because I didn't do the site visit in L.A. , and I of course 
didn't do it in San Francisco, but was very interested. I 
remember going to Chicago, where I knew the politics, and when 
we were doing our site visit anyone could come from wherever to 
talk. The Howard Brown Memorial Clinic, which was the main gay 
clinic there, came in to talk down the group that had applied. 
Which was upsetting to me, but it indicated that we weren't 
going to get that cooperative, collaborative kind of process, 
so we turned that proposal down. So it varied in communities. 
Houston just couldn't get it together; Dallas did. 



181 



Kathy Whitmire was the mayor in Houston. When we went 
into her office, she introduced herself. She didn't introduce 
herself to me, because she knew me through my work with Dianne 
Feinstein at the mayoral association meetings. But she 
introduced herself to everyone else there, including her AIDS 
coordinator! I realized that we had a real problem if she had 
to introduce herself to her own AIDS coordinator. So that 
didn't help their proposal --they obviously couldn't get it 
together. 



The Media 



Hughes: Would you care to comment on the media's role in the epidemic 
in San Francisco? 

Silverman: They basically did an excellent job. I did have some problems 
with Randy Shilts, which I think I may have mentioned dealt 
with his biased reporting. However, I believe this community's 
journalism, electronic and print, outstripped all others. In 
fact, in a meeting in New York in I guess it was '85 or '86 on 
the media's role in the AIDS epidemic, Randy made the point 
that the San Francisco Chronicle had carried twice as many 
column inches on AIDS as the New York Times, L.A. Times, and 
Washington Post combined. 

Hughes: Amazing. 

Silverman: KPIX [TV] was doing a lot. In fact, I was a consultant for 

KPIX on AIDS when I left the health department in 1985. They 
had an AIDS reporter. Very few other communities did. 

After the media, nationwide, started getting on the 
bandwagon- -probably a bad choice of words--! really felt they 
were doing more than the government was doing. We needed the 
media because the government just wasn't doing what needed to 
be done in the area of public information. 

Hughes: As director of the health department, did you use the media to 
get your message out? 

Silverman: Definitely. In fact, I remember doing public service 

announcements, which they were very cooperative in running on 
TV. I remember doing one in December of '84 when we had just 
recently found the first heterosexual case. We had a gay man 
with AIDS to talk about gay men doing things to protect 
themselves, and I did one for the heterosexuals. 



182 



Hughes: Did your exposure to the media increase with the AIDS epidemic? 

Silverman: Well, I always had a very open door to the press. So I was on 
a first-name basis with probably at least one reporter from 
every news outlet. I've always felt that they should have 
access, since we were working for the public. 

Now, it increased during the AIDS epidemic, but I don't 
know if it increased more proactively or reactively. I tend to 
think it increased more reactively, because AIDS raised so many 
different issues that pushed so many buttons. 



The Federal Government's Response to the Epidemic 



Hughes: Would you like to comment on how you view the government's 
response? 

Silverman: With regard to the Reagan and Bush administrations- -in a word, 
abysmal. It wasn't for lack of care and initiative and 
creativity on the part of many working in the federal 
government; it was the inability to get anything past the 
administration that wasn't of the pablum variety. 

Hughes: What were the reasons for that? 

Silverman: A conservative agenda in the administration. They weren't 
going to talk about sex; they weren't going to talk about 
condoms; they weren't going to talk about homosexuality. It 
took them years to get that first mailing on AIDS to every 
household. 1 Switzerland I think had already sent a second 
mailing, and they had fewer cases nationwide than we had in San 
Francisco. I usually ask every audience I speak to, "How many 
of you have heard of 'America Responds to AIDS?'" (It is the 
federal government's information program which until recently 
provided only the most insipid messages.) Whether I'm talking 
to fifty or five thousand, I generally get only a few hands. 

The public service ads were so unmeaningf ul . One that 
just came out several years ago showed a beach ball bouncing 
across the screen, and the voice-over or the print-over was, 
"You can't get AIDS from a beach ball." [laughter] To me, 



^Understanding AIDS," a plain- language AIDS -information pamphlet, was 
sent by Surgeon General C. Everett Koop's office to every American 



household in 1988. 
1991, pp. 54-56.) 



(Surgeon Koop, Gregg Easterbrook, Whittle Direct Books, 



183 



that means that if you play with a beach ball, you don't have 
to wear a condom. This was the kind of drivel that came out, 
not because there was lack of creativity and initiative, but 
because the administration just wouldn't allow it. 

Hughes: Do you remember when "America Responds to AIDS" started? 

Silverman: I would say '87, '88. Some very good people were so frustrated 
over it that they told the CDC they just couldn't continue to 
work there. 

Hughes: Does this relate to your work in 1987 with some of Reagan's 
speechwriters? 

Silverman: No. That was an interesting thing. Reagan was going to speak 
for the first time on AIDS at AmFAR's awards ceremony. I was 
going to be the host for the evening. I suggested that if the 
speechwriters were going to write his speech, I would like to 
meet with them, which I did. I spent several hours over lunch 
going over what I thought the president should say. 

I had heard that Gary Bauer had gotten to him too. Gary 
Bauer was one of William Bennett's domestic advisors, somebody 
just to the right of Ghengis Khan. He's head of one of these 
family-values organizations now. After I introduced the 
president, I was standing off to the side, and my wife was 
sitting in the first or second row. 

As he started giving the speech, we acknowledged to each 
other those comments that resulted from my input. I was really 
feeling good, because he was talking about compassion and 
caring, and the need to fight the virus, not the person- - 
nothing terribly esoteric, but appropriate. And then he went 
into the second half of the speech, which was obviously Gary 
Bauer's: "We have to have a test, and the tests have to be 
mandatory." Then there were hoots and hollers and boos from 
the audience, and of course, that's all the media picked up. 

I remember complaining to one of the media people that the 
first part was not covered, not because I had written it, but 
because it was so important for the nation to hear the 
president say it. And he said to me, "Why is that important? 
Any president should say it." I said, "Yes, but he hasn't." 
This was six, seven years into the epidemic, and he hadn't said 
it. For a middle American to hear the president saying, "We 
can't discriminate--" was important. But the media only 
covered the controversy. 

Hughes: Because that made news. 



184 



Silverman: So that was my lone speechwriting effort for the president. He 
lifted phrases right out from what I gave him. So I felt good 
about it, but it was wasted, except for the people in the 
audience, whom I'm sure will not remember any of those remarks. 



Transcribed and Final Typed by Shannon Page 



185 



TAPE GUIDE The AIDS Epidemic in San Francisco: The Medical Response, 
1981-1984, Volume I 



Interviews with Selma K. Dritz, M.D., M.P.H, 

Interview 1: June 24, 1992 
Tape 1, Side A 
Tape 1, Side B 



Interview 2: 
Tape 2, 
Tape 2, 
Tape 3, 



Interview 3: 
Tape 4, 
Tape 4, 
Tape 5, 



Interview 4: 
Tape 6, 
Tape 6, 
Tape 7, 



June 29, 
Side A 
Side B 
Side A 



1992 



Tape 3, Side B not recorded 



July 6, 
Side A 
Side B 
Side A 



1992 



Tape 5, Side B 



July 8, 1992 
Side A 
Side B 
Side A 



Tape 7, Side B not recorded 



1 
12 



17 
27 
36 



46 
56 
66 

77 



85 

95 

104 



Interviews with Mervyn F. Silverman, M.D., M.P.H, 



Interview 1 : 
Tape 1 
Tape 1. 
Tape 2, 



March 23, 
Side A 
Side B 
Side A 



1993 



Tape 2, Side B not recorded 



Interview 2: 
Tape 3, 
Tape 3, 
Tape 4, 



May 10, 1993 
Side A 
Side B 
Side A 



Tape 4, Side B 

Interview 3: July 6, 1993 

Tape 5, Side A 

Tape 5, Side B 



107 
123 
133 



138 
147 
156 
168 



170 
175 



186 

APPENDICES--The AIDS Epidemic in San Francisco: The Medical 
Response, 1981-1984, Volume I 



A. AIDS Chronology, 1981-1984 187 

B. Key Participants in San Francisco AIDS History, 1981-1984 199 

C. Dritz materials San Francisco City Clinic Forms and 

Guidelines 202 

D. Curriculum vitae, Selma K. Dritz, M.D., M.P.H 230 

E. Silverman materials documents relating to the closing 

of the bathhouses 234 

F. Curriculum vitae, Mervyn F. Silverman, M.D., M.P.H. 268 



187 
AIDS CHRONOLOGY, 1981-1984 1 



Appendix A 



1968-1970 David Baltimore and Howard Temin independently discover reverse 
transcriptase, a marker for retroviruses. 

1974 Charles Garfield founds Shanti Project to provide free volunteer 
counseling to people with life-threatening illnesses. 

1976 Robert Gallo isolates T-cell growth factor (interleukin-2) , allowing 
T-cells to be cultured in vitro. 

1978 San Francisco Mayor George Moscone assassinated; Dianne Feinstein 
becomes mayor. 

1980 Gallo demonstrates that retroviruses (HTLV-I and HTLV-II) can infect 

humans . 

1981 

Feb. Drew et al. document prevalence of cytomegalovirus [CMV] in 
homosexuals . 

Feb. Michael Gottlieb, UCLA, diagnoses Pneumocystis carinii pneumonia 
[PCP] in two homosexuals. 

Mar. Gottlieb diagnoses another case of PCP in a homosexual. 

Mar. Sandra Ford, drug technician for Centers for Disease Control [CDC], 
officially notes increase in requests for pentamidine, for treatment of 
PCP. 

Apr. Gottlieb diagnoses two more cases of PCP in homosexuals. 

By June CDC establishes Kaposi's Sarcoma/Opportunistic Infection Task 
Force; James Curran head. 

June 6 CDC's Morbidity and Mortality Weekly Report [MMWR] publishes 
Gottlieb and Wayne Sandera's report on PCP in 5 gay men. 

July 3 First press report of syndrome appears in New York Times. 



1 This chronology is an ongoing working draft created to assist the 
oral history project; its focus is San Francisco and its accuracy is 
contingent upon the many sources from which it was derived. 



188 

July 7 MMWR reports Kaposi's sarcoma [KS] and PCP in 26 gay men. 
July 13 First article on AIDS in New York Native. 

July City of San Francisco establishes reporting and case registry system 
for AIDS. 

Aug. 28 MMWR reports first heterosexuals with AIDS. 

Aug. CDC requires health departments to notify CDC of all AIDS cases. 

Sept 15 CDC and National Cancer Institute sponsor workshop on KS and 
opportunistic infections [01]. CMV leading candidate for cause. 

Sept 21 First KS Clinic held at UCSF. 

Oct. CDC launches case-control study of factors in homosexual environment 
possibly causing KSOI . 

Oct. Friedman-Kien et al. begin study of clinical course of KS in gay men. 

Nov. Shanti begins to focus on psychosocial problems of people with AIDS 
[PWA]. 

Dec. 9 Marcus Conant passes out flyers on KS at American Academy of 
Dermatology meeting in San Francisco. 

Dec. 10 Durack at Duke suggests amyl nitrites might cause immune 
dysfunction. 

Dec. 10 New England Journal of Medicine article links immune deficiency to 
T4 helper cell/T8 suppressor cell ratio. 

Dec. First clinical descriptions of immunosuppression in IV drug users. 

Dec. John Ziegler, Conant and Paul Volberding receive $50,000 from 
American Cancer Society to support KS Clinic at UCSF; first grant awarded 
for AIDS. 

CDC investigators suspect that causal agent of AIDS is infectious but 
cannot provide irrefutable evidence. 

Reagan proposes massive cuts in CDC budget. 

1982 

Early 1982 Syndrome is named gay-related immunodeficiency disease--GRID. 



189 

Jan. First case of immune deficiency linked to blood products is reported 
in a hemophiliac. 

Jan. Helen Schietinger becomes nurse-coordinator of KS Clinic at UCSF. 

Jan. San Francisco health department makes first request for tax funds to 
support AIDS prevention and community services; Board of Supervisors 
appropriates $180,000 for AIDS programs. 

Mar. MMWR lists four risk groups for AIDS--homosexuals, hemophiliacs, 
Haitians, and IV drug users [IVDUs]. 

Apr. Congressional subcommittee hearing in Los Angeles on AIDS, Henry 
Waxraan (D-CA) , chairman. 

May 15 Friedman-Kien et al. publish study showing promiscuity greatest 
risk factor for KS . Authors support immune overload theory of AIDS 
causation. 

June 18 CDC reports cluster of PCP and KS cases in LA and Orange County, 
suggesting infectious agent is cause of AIDS. 

June KS Research and Education Foundation established in San Francisco. 

July 9 CDC publishes first report of 31 cases of opportunistic infections 
in Haitians. 

July 13 First international symposium on AIDS, at Mt. Sinai Medical Center, 
New York, sponsored by Mt. Sinai and New York University [NYU] schools of 
medicine . 

July 16 MMWR reports first three cases of PCP in hemophiliacs, 
representing first cases of AIDS caused by blood or blood products. 

July 27 CDC adopts "acquired immune deficiency syndrome- -AIDS" as the 
official name of the new disease. 

Aug. CDC asks blood banks not to accept high-risk donors; CDC recommends 
hepatitis B core antigen testing. 

Sept. 24 CDC defines AIDS as disease due to defect in cell-mediated 
immunity occurring in people with no known cause for immune deficiency. 

Sept. 24 CDC first uses term "AIDS", in MMWR. Rapid adoption of term. 

Oct. KS Research and Education Foundation contracts with San Francisco 
Department of Public Health [SFDPH] to provide AIDS education services in 
San Francisco. 



190 

Nov. MMWR suggests that hospital staffs caring for AIDS patients use 
hepatitis B precautionary measures. 

Dec 1 House of Representatives votes $2.6 million to CDC for AIDS 
research. 

Dec. 4 CDC presents Blood Products Advisory Committee with evidence that 
AIDS being spread through blood supply; no official action taken. 

Dec. 10 Ammann, Cowan, Wara et al. report first case of possible 
transfusion AIDS, in MMWR. 

Dec. 17 MMWR reports four cases of unexplained immune deficiency in 
infants. 

Dec. Shanti makes first in series of contracts with SFDPH to provide 
counseling services and a housing program for PWA. 

Late 1982 Most investigators convinced that AIDS is caused by an 
infectious agent. 

UCSF symposium on AIDS is attended by nearly 200 MDs and researchers. 

Nation's first and largest AIDS specimen bank established at UCSF, 
coordinated by KS Clinic. 

1983 

Early in year: Beginning of bathhouse crisis. Formal AIDS infection 
control guidelines instituted at San Francisco General Hospital. 

Jan.l First outpatient clinic dedicated to AIDS (Ward 86) opens, at San 
Francisco General Hospital. 

Jan. A CDC national conference to determine blood bank policy re testing 
blood for HIV but fails to reach consensus. 

Jan. 7 San Francisco's Irwin Memorial Blood Bank [IMBB] adds medical 
history questions designed to screen out donors from high-risk groups. 

Jan 14 National Hemophilia Foundation asks blood and plasma collectors to 
screen out high-risk donors. 

Jan. 19 Irwin Memorial Blood Bank adds more medical history questions. 

Jan. Luc Montagnier, Barre-Sinoussi, and Chermann at Pasteur Institute, 
seeking to isolate an AIDS virus, begin to grow cells from lymphadenopathy 
patient. 



191 

Jan. 7 CDC adds heterosexual partners of AIDS patients as fifth risk group 
for AIDS. 

Jan. 25 Montagnier et al. find traces of reverse transcriptase in 
lymphadenopathy cell cultures. 

Jan. President of New York Blood Center denies evidence of transfusion 
AIDS. 

Jan. Orphan Drug Act becomes law, giving exclusive marketing rights, tax 
breaks, and other lucrative incentives to companies developing drugs for 
rare diseases. 

Feb. 3 Physicians from UCSF KS Study Group urge IMBB to use hepatitis B 
core antibody test to screen out blood donors with AIDS. 

Feb. 7 IMBB launches confidential questionnaire designed to detect 
potential blood donors with AIDS. Bay Area Physicians for Human Rights 
urges potential donors to refrain from donating if they have AIDS symptoms. 

Feb. At Cold Spring Harbor Workshop on AIDS, Robert Gallo suggests that a 
retrovirus probably causes AIDS, presumably a variant of HTLV-I or HTLV-II. 

Mar. CDC establishes clinical definition of AIDS in attempt to standardize 
epidemiological surveillance. 

Mar. UCSF Task Force on AIDS created, mainly to establish infection 
control policy. 

Mar. A MMWR advises members of four AIDS risk groups to defer blood 
donation: gays with multiple sex partners, IVDUs, Haitians, and 
hemophiliacs . 

Mar. A CDC states that "available data suggests that AIDS is caused by a 
transmissible agent." 

Mar. 2 A Federal Drug Administration [FDA] issues donor screening 
guidelines . 

Mar. California requires reporting of AIDS cases, but not AIDS-Related 
Complex [ARC]. 

Mar. Public Health Service [PHS] recommends members of high risk groups 
reduce number of sex partners. 

Mar. Mervyn Silverman, SFDH director, forms Medical Advisory Committee on 
AIDS. 



192 

Apr. 11 Date NCI officials later cite as when NCI became committed to 
finding AIDS etiology. 

Apr. 14 Irwin Memorial Blood Bank adds donor sheet designed to screen out 
donors at high risk for AIDS. 

Apr. 26 Recall of Feinstein, supported by White Panthers and some gay 
groups, fails. 

Apr. Congressman Phillip Burton dies; Sala Burton eventually is elected to 
his seat. 

Apr. City of San Francisco and Shanti open hospice-type care center for 
neediest AIDS patients. 

Apr. Conant, Volberding, John Greenspan, Frank Jacobson, and others 
persuade Willie Brown to ask for $2.9 million in state funding for AIDS 
research. 

May 6 Journal of the American Medical Association [JAMA] press release: 
"Evidence suggests household contact may transmit AIDS." 

May NIH announces $2.5 million for AIDS research. 

May Heat treatment, developed at UCSF, to reduce infectious agents in 
transfused blood approved by FDA. 

May SF health department issues first brochure on AIDS. 

May Feinstein declares first week in May AIDS Awareness Week. 

May 2 "Fighting for our Lives" march in San Francisco; similar march in 
NYC. 

May 20 Montagnier publishes discovery of "T-cell lymphotrophic 
retrovirus", later called lymphadenopathy-associated virus (LAV). Gallo 
and Essex publish three papers indicating HTLV-I as cause of AIDS. All 
four papers published in same issue of Science. Evidence inconclusive. 

May 23 San Francisco Board of Supervisors votes $2.1 million for AIDS 
programs, $1 million of which is for out- and inpatient wards at SFGH. 

May 24 Edward Brandt, Assistant Secretary of Health, declares AIDS 
research #1 priority. 

May 31 Mervyn Silverman, backed by Feinstein and Board of Supervisors, 
requires city bathhouses to post public health warnings about contracting 
AIDS. 



193 

June $1.2 million grant awarded to Volberding and Conant for AIDS research 
at SFGH and UCSF--largest NIH grant for AIDS research to date. 

June UC issues guidelines to protect AIDS patients and health workers. 
June San Francisco Men's Health Study begins to recruit participants. 
June Feinstein chairs first U.S. Conference of Mayors Task Force on AIDS. 

Jul. 26 Twelve-bed inpatient Special Care Unit (Ward 5B) opens at SFGH-- 
first dedicated AIDS hospital unit in U.S. 

July California legislature approves $2.9 million for UC AIDS research. 

July Adult Immunodeficiencies Clinic established at UCSF; first patients 
seen August 1. 

Aug. Willie Brown, Rudi Schmid, Conant and other AIDS researchers 
criticize UC for delays in releasing state funds for AIDS research. 

Summer Universitywide Task Force on AIDS created to advise UC president on 
guidelines for state-supported AIDS research at UC and to coordinate UC 
AIDS research. 

Set. 13 Montagnier sends Gallo sample of LAV. 

Sept. 21 UCSF Task Force on AIDS first to create infection control 
guidelines for health care workers caring for AIDS patients. 

Sept. At Cold Spring Harbor NCI meeting on human T-cell leukemia 
retroviruses, Montagnier et al. report LAV-like viruses in five 
lymphadenopathy patients and three AIDS patients, selective affinity of LAV 
for CDA helper lymphocytes, and evidence of similarities between LAV and 
lentivirus causing equine infectious anemia. Gallo presents findings of 
HTLV-I in 10 percent of AIDS patients; doubts LAV is retrovirus. 

Sept. UC states that there is no scientific reason for healthy medical 
personnel to be excused from caring for AIDS patients. 

Nov. KS Research and Education Foundation contracts with State of 
California Department of Health Services to provide information and 
referral services on AIDS to other counties. 

Nov. Mika Popovic in Gallo 's lab discovers method for growing HIV in T- 
cells. 

Nov. SF Department of Public Health asks for legal option to make baths 
off-limits to PWA. Lawyers decide that medical uncertainties about AIDS 
prevent such action. 



194 

Nov. Jay Levy obtains six viral isolates from AIDS patients but decides 
not to publish until further proof. 

Dec. Pasteur Institute applies for U.S. patent on diagnostic kit based on 
ELISA test for LAV antibodies. 

Dec. Feinstein votes against live-in lover legislation, angering gay 
community. 

Department of Health and Human Services declares AIDS top health priority 
in U.S. 

AIDS Clinical Research Centers established at UCSF and UCLA to collect 
clinical and laboratory data. 

National Association of People with AIDS formed. 
Entry "AIDS" added to Cumulated Index Medicus . 

Hospice of San Francisco contracts with SFDPH to include AIDS patients in 
its care of terminally ill. 

1984 

Jan. 12 NEJM publishes CDC documentation of first eighteen transfusion- 
associated AIDS cases. 

Jan. Annals of Internal Medicine reports case of heterosexual transmission 
of AIDS before overt manifestation of disease (hemophiliac to wife). 

Jan. American Red Cross, American Association of Blood Banks, and Council 
of Community Blood Centers oppose proposal to screen out high-risk groups 
from blood donor pool. 

Feb. Chermann in talks in U.S. states that French have discovered LAV. 

Mar. 2-4 19th Annual SF Cancer Symposium, "Cancer and AIDS". Conant, 
Abrams, Wofsy, Ziegler, Volberding speak. 

Mar. 6 Blood industry task force meets on surrogate testing; blood bankers 
oppose it. 

Mar. 26 Government allots $1.1 million to develop AIDS antibody test to 
seven institutions, including Irwin Memorial and Stanford blood banks. 

Mar. President of New York Blood Center continues to deny HIV transmission 
by blood. 



195 

Mar. Larry Littlejohn, gay activist, sponsors San Francisco ballot 
initiative to close baths. 

Apr. 9 Silverman and state and SF health officials outlaw sex in 
bathhouses, rather than close them. 

Apr. 24 Margaret Heckler, Secretary of Health and Human Services, 
announces discovery by Gallo et al. of AIDS virus, that an AIDS test will 
be available soon, and that a vaccine will be available in 18-24 months. 
Gallo had not yet published his results. 

Apr. Feinstein issues first formal statement that Silverman should close 
baths. Silverman says that he will formulate guidelines banning sex 
activity that spreads AIDS in baths. 

Apr. NIH applies for patents on Gallo's AIDS antibody test, a diagnostic 
kit based on Western blot technique. 

May 1 IMBB and other Bay Area blood banks begin testing blood for 
hepatitis B core antigen. 

May Gallo publishes four reports and Montagnier one, in Science, linking 
AIDS with a new retrovirus which Gallo calls HTLV-III and Montagnier calls 
LAV. 

May Board of Supervisor's president Wendy Nelder chides Silverstein for 
"shameful" delays in proposing sex guidelines for baths. Silverman replies 
that he is waiting for board to transfer authority to regulate baths from 
police to health department. 

May Rock Hudson diagnosed with AIDS. 

FDA gives Syntex permission to distribute ganciclovir for CMV retinitis on 
compassionate use basis. 

Summer Silverman orders bathhouse surveillance for unsafe sex. 

June Board of Supervisors committee delays action on giving health 
department authority to regulate baths until after Democratic National 
Convention in SF. 

June IMBB adopts directed blood donation program. 
July Democratic National Convention in San Francisco. 

Aug. After gay lobbying, Board of Supervisors tables move to give 
Silverman regulatory power over baths, killing his idea to promulgate sex 
guidelines for baths. 



196 

Aug. Levy et al. isolate virus which they claim to cause AIDS. 
Sept. Chiron Corp. announces cloning and sequencing of ARV genome. 
Sept. Giovanni Battista Rossi in Italy isolates HIV. 

Sept. 60 physicians at Pacific Medical Center sign petition asking baths 
to be closed. 

Oct. 9 Silverman closes baths and private sex clubs as "menace" to public 
health. Baths reopen hours later. 

Oct. Feinstein forms Mayors Advisory Committee on AIDS. 

Oct. FDA approves Lyphomed's injectable pentamidine for PCP and gives it 
orphan drug status. 

Nov. 28 SF Superior Court Judge Roy Wonder rules baths can remain open if 
monitored for safe sex practices every 10 minutes. 

Nov. Gallo et al. clone HTLV-III. 

Dec. Montagnier et al. report cloning of LAV-1; they also report CD4 
molecule as HIV receptor. 

Dec. 26 Simon Wain-Hobson, Pierre Sonigo, Olivier Danos, Stewart Cole, and 
Marc Alizon at Pasteur Institute publish LAV nucleic acid sequence in Cell. 

Dec. Silverman resigns as director of SFDPH. 

Dec. 90 reported cases of transfusion AIDS; 49 reported cases of Factor 
VIII hemophilia cases. 

CDC recommends use of heat-treated blood products for hemophiliacs; other 
specialists differ. Heat-treated blood products become commercially 
available. 

National Kaposi's Sarcoma Foundation renamed SF AIDS Foundation. 
1985 

Jan. 14 Irwin Memorial Blood Bank prohibits males having more than one sex 
partner to donate blood. 

Jan. Gallo et al. publish full nucleic acid sequence of HTLV-III. 
Jan. Jay Levy announces virus which he call AIDS-Related Virus (ARV). 



197 

Feb. 1 Paul Luciw, Jay Levy, Ray Sanchez-Pescador et al. publish ARV 
nucleic acid sequence. 

Feb 7 Dan Capon, M.A. Muesing et al. at Genentech publish ARV nucleic acid 
sequence. 

Feb. FDA approves Gallo's AIDS diagnostic kit based on Western blot 
technique. 

Mar. 2 FDA approves Abbott Laboratory's commercial test for AIDS. Red 
Cross contracts with Abbott, one of five companies supplying test, and in 
days phases in test. Britain and France delay testing six months to 
introduce their own antibody tests. 

Mar. 3 IMBB introduces genetically engineered hepatitis B antibody core 
test. 

Mar. 6 IMBB institutes anti-HIV antibody test, the first blood bank in 
U.S. to do so. 

Mar. 14 San Francisco Chronicle reports army study showing AIDS 
transmission through heterosexual contact. 

Mar. County Community Consortium founded for community-based AIDS drug 
testing. 

Spring California legislature and Gov. Deukmejian approve bill banning HIV 
antibody testing without subject's written informed consent, except at 
alternate test sites where testing is anonymous. Bill also bars employer 
and insurance company discrimination on basis of HIV status. $5 million 
appropriated to establish HIV community test sites. Disclosure of test 
results to third party must be improved in writing by test taker. 

May U.S. Patent Office awards patent on Gallo's antibody test. 

Summer AIDS diagnostic kits using ELISA become commercially available. 
California law mandates every county to offer AIDS test at public health 
centers; guidelines for preserving confidentiality. 

June 24 IMBB adds bar codes for confidential exclusion of blood units. 

June American Association of Blood Banks, American Red Cross, Council of 
Community Blood Centers agree not to begin "look back" program to identify 
people who have received HIV-infected blood. 

June National Institute of Allergy and Infectious Diseases [NIAID] creates 
first AIDS Treatment Evaluation Units, predecessor to AIDS Clinical Trial 
Groups (ACTGs). 



198 

June California public health clinics begin testing for AIDS. 

Sept. Mathilde Krim and Michael Gottlieb found American Foundation for 
AIDS Research, merging AIDS Medical Foundation of New York and National 
AIDS Research Foundation of Los Angeles. 

Sept. Martin Delaney and others found Project Inform. 

Oct. Public's awareness of AIDS rises with Rock Hudson's death. Congress 
allots $70 million to AIDS research day after Hudson's death. 

Dec. Pasteur Institute goes to court to win share of royalties on HIV 
antibody test. 

Dec. CDC first considers vertical transmission of HIV; advises infected 
women to "consider" delaying pregnancy until more known about perinatal 
transmission of HIV. 

CDC contracts with SF AIDS Foundation to develop materials for anonymous 
AIDS testing sites. 

First International Conference on AIDS, Atlanta. 

Late in year Department of Defense announces that new recruits will be 
screened for AIDS and rejected if positive. 

Third UC AIDS Clinical Research Center founded at UC San Diego. Goals of 
three centers broaden to include rapid evaluation of new therapeutic 
agents . 

13-year-old Ryan White, a hemophiliac with AIDS, is barred from school in 
Indiana. 



199 

KEY PARTICIPANTS 

in San Francisco AIDS History, 1981-1984 
Appendix B 

*'Donald A. Abrams, M.D. , AIDS clinician and member of original AIDS physician 
team at San Francisco General Hospital (SFGH); early research on AIDS- 
associated lymphadenopathy (swollen lymph glands); organizer of County 
Community Consortium. 

*Arthur J. Ammann, M.D. , pediatric immunologist at University of California, 
San Francisco (UCSF) ; conducted early studies of AIDS-associated immune 
deficiency in adults and children; reported first case of transfusion AIDS; 
currently head of a pediatric AIDS foundation. 

Francoise Barre-Sinoussi, retrovirologist at Pasteur Institute and member of 
team which isolated AIDS virus. 

Edward N. Brandt, Jr., M.D. , Ph.D., Assistant Secretary for Health, U.S. 
Department of Health and Human Services, 1981-1984. 

Conrad Casavant, immunologist in Department of Laboratory Medicine and 
associate director of Clinical Immunology Laboratory at UCSF; died of AIDS in 
1987. 

Jean-Claude Chermann, retrovirologist at Pasteur Institute and member of team 
which isolated AIDS virus. 

*Marcus A. Conant , M.D. , clinical professor at UCSF, and dermatologist with 
private AIDS practice; diagnosed first case of Kaposi's sarcoma in San 
Francisco; founder of first AIDS clinic (at UCSF); medical activist at local, 
state, and federal levels. 

James W. Curran, M.D. , M.P.H., epidemiologist and director of AIDS research at 
Centers for Disease Control (CDC), Atlanta, Georgia. 

William Darrow, CDC sociologist. 

Larry Drew, virologist at Mt. Zion Hospital, San Francisco. 

*Selma K. Dritz, M.D. , M.P.H., epidemiologist at San Francisco Department of 
Public Health (SFDPH); tracked early AIDS cases in San Francisco; addressed 
medical and community groups on AIDS recognition and prevention. 

Gaetan Dugas, French-Canadian airline steward who was among first to be 
diagnosed with AIDS; sometimes mistakenly referred to as "Patient Zero" and 
held responsible for early dissemination of AIDS. 



1 The asterisk indicates that the individual has been interviewed for the 
AIDS oral history series. 



200 

Edgar Engleman, M.D. , medical director of Stanford University Hospital blood 
bank. 

Anthony S. Fauci, M.D., director of AIDS activities at National Institute of 
Allergy and Infectious Diseases, later director of Office of AIDS Research, 
currently director of NIAID, National Institutes of Health (NIH) . 

*Donald P. Francis, M.D. , D.Sc., epidemiologist and virologist at CDC in 
Phoenix and Atlanta; conducted early epidemiological and virological studies 
of AIDS; later became CDC advisor on AIDS to California Department of Health 
Services; current director of research on AIDS vaccines at a biotechnology 
company. 

Robert Gallo, M.D. , retrovirologist at National Cancer Institute, NIH, 
involved in controversy with Pasteur Institute over isolation of AIDS virus 
and patent rights to HIV test. 

*Deborah Greenspan, D.D.S., D.Sc., clinical professor of oral medicine at 
UCSF; identified AIDS-associated hairy leukoplakia; instrumental in 
establishing infection control procedures in dentistry. 

*John S. Greenspan, D.D.S., Ph.D., professor of oral biology and oral 
pathology at UCSF; organized and directs UCSF AIDS specimen bank; current 
director of UCSF AIDS Clinical Research Center. 

Margaret Heckler, Secretary of U.S. Department of Health and Human Services, 
1983-1985. 

Harold Jaffe, epidemiologist with the AIDS program at CDC. 

*Jay A. Levy, M.D. , virologist and professor of medicine at UCSF; second to 
isolate AIDS virus; devised early AIDS diagnostic test and heat treatment to 
rid blood of HIV. 

Luc Montagnier, virologist and member of Pasteur Institute team which isolated 
AIDS virus. 

*Andrew R. Moss, Ph.D., M.P.H., epidemiologist at SFGH; conducted early 
epidemiological studies of AIDS in San Francisco showing high incidence in gay 
community; later work focused on AIDS incidence in drug users and homeless. 

Herbert A. Perkins, M.D., scientific director (later president) of San 
Francisco's Irwin Memorial Blood Bank; involved in formulating national blood 
bank policy regarding blood screening for HIV; currently represents blood bank 
in legal cases associated with transfusion AIDS. 

*Merle A. Sande, M.D., professor of medicine and chief of medical services, 
SFGH; chairman of AIDS advisory committees at university, health department, 
and state levels. 



201 

Randy Shilts, journalist who covered AIDS for San Francisco Chronicle; author 
of And the Band Played On: Politics, People, and the AIDS Epidemic; died of 
AIDS in 1994. 

*Mervyn F. Silverman, M.D., M.P.H., director, San Francisco Department of 
Public Health; center of controversy over closure of San Francisco bathhouses; 
current director of American Foundation for AIDS Research. 

*Paul A. Volberding, M.D., oncologist and chief of AIDS Services, SFGH; member 
of original AIDS physician team at SFGH; prominent AIDS clinician. 

Girish Vyas , Ph.D., professor of laboratory medicine, UCSF. 

*Warren Winkelstein, M.D. , M.P.H., epidemiologist at University of California 
School of Public Health; director of early on-going epidemiological study of 
AIDS (San Francisco Men's Health Study); member of panel deciding in June 1994 
to disprove expanded clinical trial of two AIDS vaccines. 

*Constance B. Wofsy, M.D. , infectious disease specialist at SFGH; member of 
original AIDS physician team at SFGH; authority on Pneumocystis carinii 
pneumonia and women with AIDS. 

*John L. Ziegler, M.D., oncologist at Veterans Administration Medical Center, 
San Francisco; authority on AIDS-associated lymphoraa and Kaposi's sarcoma. 



202 



Appendix C 
Dritz materials 
San Francisco City 
Clinic Forms and 
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203 



GUICELINES 



SYMPTOMS 
Persistent fever 

Drenching night sweats 
Dry cough 
Short of breath 

Less of weight 
Persistent fatigue 
Recurring headaches 
Herpes infections 

Persistent cramps, etc 

c * **ir 
i. J,O 

Swollen lymph glands 



'..'hite patches 



Chronic skin infection 



Eluish-purple spots 



low grade but over 101 'F, unexplained cause, especially in 
late afternoon and evening, for three or more weeks. 

for three or more weeks 

persistent daily for more than one week& of recent origin 

present without or minimal exertion (climbing one flight 
of stairs). 

more than ten pounds in past year without known cause 

for two or more months without cause 

no obvious cause, such as sinusitis, vision problem, etc. 

zoster in any male under 60 years and of recent Ori 9 in 
recurring "cold sores" or genital herpes with episodes 
every four - six weeks 

for one or more months without explanation 



in two or more sites for more than three months, excluding 
inguinal. Bilateral cervical would be considered two sites; 
or excessively large nodes in any one site for any duration 
without explanation of its existance, i.e. infection, 

identify presence of candidiasis with microscopic examination 
of suspect lesions with scraping and wet mount preparation 

particularly a folliculitis present more than three months 
without other explanation 

on skin and/or mucus membranes, such as in mouth or anus; 
aoes not pale on pressure. 



City Clinic-May 33 







^--.Y CLINIC AIDS srP.EEN-NS rSrCrVF.ES 204 

We will be screening for AIDS in a more organized manner starting Kay 2, 1953. 
A 5 x B card is being photocopied to be used as the patient record for this 
specific service with plans for its printing sometime in the future. It will 
be in addition to the regular Access card used in documenting all patient visits. 

1. A patient who is interested in an AIDS evaluation will be asked by the 
Screener (or by the Clinician if that is when the interest is first expressed) what 
symptoms or signs are present which makes the patient think he has AIDS. In the 
absence of significant symptoms or signs the patient can be reassured and given ap 
propriate informational pamphlet. The patient can be offered a routine VD exam 
ination by the Screeners and an Access patient record can be initiated. 

2. Only a patient having significant symptoms or signs listed on the card and to 
the extent described in the Guidelines will have a special AIDS examination card 
initiated. The presence or absence of particular symptoms, signs and history items 
will be noted by * cr - placed in the respective boxes by the Screener (or Clin 
ician). The Screener (or Clinician) dcing this should place his or her identify 
ing number or letter in the Screener box on the face of the record. This AIDS 
record will accompany a completed Access card to the Clinician. 

3. Clinician evaluation and services 

A. Perform an appropriate VD examination properly documented on the Access 
card as currently practiced. In addition, the patient's Access record will be 
stamped with "AIDS Evauation" on the dateline of the examination. Each examin 
ation room will be supplied with the stamp. 

B. Describe on the reverse side .of the AIDS clinic record the "duration, 
frequency, etc...." of the symptoms, signs and Historic factors noted as being 
present. The clinician should identify his or her notes written on back of re 
cord. 

C. Perform, a brief physical examination focusing on: 

1) Lymph nodes - cervical , axillary, popliteal and inguinal 

2) Mouth and throat - for Candida and Kaposi-lika lesions 

3) Skin - including peri-anal and soles for chronic folliculitis and 
}'aposi-like lesions 

D. Use the reaular treatment form to order skin tests for Candida and 
mumps to be applied by a nurse who will also supply the patient with an inform 
ation sheet regarding the test reading and interpretation. 

E. Place X to the left of the test ordered. Consider hematology one test 
for this curoose. Write in name of other tests that might be ordered, ie CiP. 

F. Offer ova and parasite collection kits to AIDS evaluation patients with 
cram.ps and other bowel problems. The kits contain directions for collecting spec- 
nens, where and when to return them, etc. NOTE: Start of ova and parasite testing 
may be delayed to after 5/2/83. 

G. Secure a hematology evaluation. We anticipate funding will be secured 
which will allow patients a referral for the CBC, differential and platelet 
co-ont starting in the Summer of 1933. 

In the interim the patient can pay here the fee of $11.00 ($12.00 starting 6/1) 
and we will comolete the Smith Kline Clinical Laboratories "Client Bill" slip, 
keeping the Client Copy. The patient will take the remaining parts of the lab 
slip and to to one of the five Smith Kline Labs in the City. If the patient pre 
fers to pay at the Lab, he will pay $19.00. In this latter case, we complete the 
"Patient Bill" lab slip, again keeping the Client Copy, giving the patient the 
remaining copies to the laboratory. 



he Supervisor of Registration and Tatient Services, cr designes, will complete 
-he appropriate lab slip and collect payment when indicated. If the patient 
wishesto pay the $11. CO (or $12.00) by check, the check should be made out to 



the 



205 
CITY CLINIC AIDS SCREENING PROCEDURES (continued) 



Smith Kline Clinical Laboratories. 

H. Depending on the Clinician's evaluation, a patient can be referred for 
a. definitive evaluation at the completion of our screening if the indications ar= 
strong enough. This referral will then be ir.ade before test results are available 
or even the tests ordered. 

Appointments can be made at SFGH AIDS Clinic at 995 Potrero Avenue, corner of 22r 
Street, Ward 86, 361-3830 for Thursdays from e:45 to 11:15 A.M.. Call while 
patient is in our Clinic and arrange for a photocopy of our AIDS record sent to 
SFGH with note as to date and time of appointment. 



4. Khan the disposition is being deferred until after testing results are 

back, the ST3 review physician will in axe the determination and form letter will 
will be sent to the patient which will have various options, such as referral, 
return for repeat screening, etc.. If referred, a copy of the record should be 
sent to the designated evaluating agency with note indicating patient was advised 
to ir.ake an aroointm.er.t. 

5. The AIDS Coordinator will be responsible to see that test results are posted, 
referred to review physician and to send out disposition letter to the patient. 
As indicated by a review physician follow-up phone call by AIDS Coordinator to 
selected patients to confirm compliance with recommendations can be arranged. 

6. Screeners and Clinicians should keep themselves informed as to the latest 
developments in this program area. 

7. The AIDS record will be filed numerically in a designated file drawer. 



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City and County of San Francisco 



207 



Department of Public Health 




AIDS EVAUJATION REPORT 



PATIENT NAME_ 
CC# 



1. 



2. 



DATE OF EVALUATION_ 
DOB: 



After reviewing the findings of your recent. AIDS Evaluation at this 
Clinic, we recommend: 

Your history, physical examination and lab tests do not show any 
significant increased risk of an AIDS disease at this time. If 
there is a continuation of your symptoms suggestive of possible 
AIDS, we would recommend a repeat evaluation in 6 months, or 
sooner if the intensity or number of such symptoms increase. 

Our findings suggest you may have a possible increased risk of 
having an AIDS associated disease. At the time you were seen 
here, you designated 

who would perform the more thorough medical work-up you might 
need. Photocopies of both this letter and your record is being 
sent there. Please arrange to make an appointment, telephone # 



3. 



4. 



6. 



It does not appear you have AIDS at this time. However, our reviewing 
physician finds that your history and our findings, particularly 

suggest you should seek general medical care . 



We are unable to complete your evaluation 
a) I I No report of skin tests 
b)' I No report of blood tests 

Stool Examination 

a)[ I The stool specimen examination was negative for parasites and 
enteric organisms. If you still have a problem, you should 
see a doctor for a more complete work-up. 

b)l. I The stool specimen examination showed 

you should take this letter to a doctor for further evaluation 
and possible treatment for this bowel problem. 

Other: Specify - 

If you have any questions you can call me at 864-8100 ext. 40 or 41. 



San Francisco City Clinic 



356 Seventh Street 



San Francisco, CA 94103 



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209 

Attachment 2 (A) 

CITY AND COUNTY OF SAN FRANCISCO 
DEPARTMENT OF PUBLIC HEALTH 

San Francisco City Clinic In cooperation with the: 

356 Seventh Street Centers for Disease Control 

San Francisco, California 94103 Atlanta, Georgia 30333 

Participant Consent Form for Project 24: A. Person diagnosed with AIDS. 

I freely agree to participate in the City Clinic cooperative study of 
risk factors for acquired immunodeficiency syndrome (AIDS). I understand that 
AIDS is a growing problem in San Francisco and that certain sexual practices 
may be important in its spread. By comparing information collected from 
people with AIDS with information collected from others who do not have AIDS, 
benefits to the community may include the possibility of finding the cause of 
this serious outbreak. 

I also understand that if I do not choose to participate in this study 
the medical care offered me by the City Clinic will in no way be affected. 
Furthermore, even though I consent now, I am free to withdraw at any time with 
a written or verbal statement to this effect. I understand that the only risk 
incurred by participation is that associated with having blood taken from a 
vein in my arm fainting, possible bruising and, rarely, infection. 

I understand that participation involves: 1) answering questions 
concerning my medical history and sexual habits after I was first tested for 
hepatitis Infection, and 2) having samples of blood and urine taken. Both the 
interview and having samples taken should be completed in less than one hour. 

I understand that should I have any additional questions I may call the 
City Clinic (Telephone No. 864-8100, ext . 41 or 42: Paul O'Malley) and that 
any Important medical information uncovered during the study will be made 
known to me and, at my request, my doctor. This is the extent of 
responsibility of the City Clinic. 

I understand that special care will be taken to protect the 

confidentiality of everyone who participates. Identifying information will be 
kept separate from the questionnaire as soon as the interview is completed and 
stored in a secure locked file at San Francisco City Clinic. I understand 
that the questionnaire will be identified only by oy Hepatitis B Study Number 
and the link between name and number will only be available to the cohort 
study coordinator and his immediate staff. I have been assured that I will 
not be identified by name in reporting of any study results. I understand 
that all study data will be kept in locked cabinets and will remain as 
confidential as possible under the law. 

I have read this consent fora and have been given the opportunity to ask 
any questions relevant to my participation. 

Date: Signed: ^ (Participant) 

Interviewer: 



rti LaciiceriL ^. .. j 

CITY AND COUNTY OF SAN FRANCISCO 
DEPARTMENT OF PUBLIC HEALTH 



210 



San Francisco City Clinic 

356 Seventh Street 

San Francisco, California 94103 



In cooperation with the: 
Centers for Disease Control 
Atlanta, Georgia 30333 



Participant Consent Form for Project 24: B. Person not diagnosed with AIDS. 

I freely agree to participate in the City Clinic cooperative study of 
risk factors for acquired immunodeficiency syndrome (AIDS). I 'understand that 
AIDS is a growing problem in San Francisco and that certain sexual practices 
may be important in its spread. I understand that personal benefits of 
participation may include knowledge of my current health status and proper 
referral should I be found to have evidence of AIDS. By comparing Information 
collected from people with AIDS with information collected from others who do 
not have AIDS, benefits to the community may include the possibility of 
finding the cause of this serious outbreak. 

I also understand that if I do not choose to participate in this study 
the medical care offered me by the City Clinic will in no way be affected. 
Furthermore, even though I consent now, I am free to withdraw at any time with 
a written or verbal statement to this effect. I understand that the only risk 
incurred by participation is that associated with having blood taken from a 
vein in my arm fainting, possible bruising and, rarely, infection. 

I will incur no added risks for AIDS by participating in this study. 
Whatever the risk of acquiring AIDS may be, it will be the same whether I 
participate or not. 

I understand that participation involves: 1) answering questions 
concerning my medical history and sexual habits after I was first tested for 
hepatitis infection, 2) having samples of blood and urine taken, and 3) having 
a physical examination for signs of AIDS. The Interview should be completed 
in less than one hour and the physical examination should be completed in less 
than 15 minutes. 

I understand that should I have any additional questions I may call the 
City Clinic (Telephone No. 864-8100, ext . 41 or 42: Paul O'Malley) and that 
any important medical information uncovered during the study will be made 
known to me and, at my request, my doctor. This is the extent of 
responsibility of the City Clinic. 

I understand that special care will be taken to protect the 

confidentiality of everyone who participates. Identifying information will be 
kept separate from the questionnaire as soon as the interview is completed and 
stored in a secure locked file at San Francisco City Clinic. I understand 
that the questionnaire will be identified only by my Hepatitis B Study Number 
and the link between name and number will only be available to the cohort 
study coordinator and his immediate staff. I have been assured that I will 
not be identified by name in reporting of any study results. I understand 
that all study data will be kept in locked cabinets and will remain as 
confidential as possible under the law. 

I have read this consent form and have been given the opportunity to ask 
any questions relevant to my participation. 



Date: 



Signed: 



(Participant) 



Interviewer: 



211 
AIDS IN A COHORT OF MALE CLINIC PATIENTS: OBSERVATIONAL STUDY 1983-1984 

San Francisco City-County Health Department Centers for Disease Control AIDS Project ; 



PATIENT: CO 1 |__ _ _ 

01 02 03 04 

DATE OF ENTRY Mp_nth_ _Day_ _X ea _ 

INTO COHORT: | | |_| |_| |_| |_| |_| 

09 10 11 12 13 14 



LAST KNOWN ADDRESS: 
City 



AIDS CASE NO. 



05 06 07 '( 



HBV TEST STATUS (CIRCLE ONE 
O.Neg l.Ag 2. An 3.0th 9-Unk 



TEL: AC I 



HI |""l HI HI State 
" TT "23 17 IT 



ZIP 



26 27 
Month Day _Jfear_ RACE (Circle One): 



16 17 18 19 20 



28 29 30 31 



honth_ _Day_ _X ea _ RACE (Circle One): _ Assigned to: 

DATE OF BIRTH | || || || || || I 1- White 3. Hlsp. 5. Amerin |_| |_ 

33 34 35 36 37 38 2. Black 4. Asian 6- Other 39 " " 



40 



ATTEMPTS TO CONTACT PATIENT; 

No 

Month Day Year Hour Minutes Attempt to Contact Ans 

First Telephone 

IZI IZI IZI IZI IZI IZI IZI IZI IZI IZI can |-| o 

42 43 44 45 46 47 48 49 50 51 52 

Second Telephone 

'~\ HI IZI IZI D IZI IZI IZI IZI IZI caii | i o 

53 54 55 56 57 58 59 60 61 62 6l 

Third Telephone 



Ct . Unk- Oth 
Pt . nown er 



Commenl 



First Letter 



75 76 77 78 79 80 



82 83 84 85 86 87 



Codes: 

C-Re turned 
1-Not Ret. 


81 
Follow-up Letter 

HI 








88 
Site Visit 

HI 


Codes: 
0-Pt . Moved 
1-Not Moved 



1 2 3 
123 
1 2 3 
1 2 3 



89 90 91 92 93 94 95 

Appt. for Interview 

IZI IZI IZI IZI IZI IZI Cl IZI Cl IZI HI o 

96 97 98 99 100 101 102 103 104 105 " 106 



Disposition (Circle One): 0. Alive, Refused interview 4. Deceased, Previously intervie 

1. Alive, Int. scheduled 5. Deceased, Not interviewed 

| | 2. Unable to Participate 6. Other: 

107 3. Unable to Locate 

Month _Day_ Year 
DATE OF DEATH: | || || || || || |CAUSE: 

~ itlS" iTo" ITT ITT ill 



9* Unknown 



AIDS Related? 

HI HI HI HI !* 2-Ko 9.1 
TT4 TT5 TT6 TT7 



LAST KNOWN ADDRESS: 



H| Cl IZI IZI State 
119 120 121 122 



IZI IZI 
123 124 



ZIP 



I ' ' - - - ' 

125 126 127 1 



atient GO 1 _ 



212 
AIDS Project 24 



Page 2 





'0 CITY CLINIC HISTORY: From Date of Entry into Cohort to Date of Last Clinic Visit. 


Month Day 


Year Disease Codes :0 12335 Code Comment : 






1 II 


| | Gonorrhea Never U R P E Multiple | 






1 II 


| | Syphilis Never 1 2 3 E Other 


Month Day 


No Diagnosis: 
Year Visit DX GC Syph Both Oth Unk Code Comment: 


P || 


| | First 1 2 3 A 5 


bzn 


| | Second 012345 


1 1 


| | Third 012345 


ZIZN 


| | Fourth 012345 


_!_!! 


| | Fifth 012345 


1 1 1 


~~| |~ Sixth 012345 I 


pzii 


| | Seventh 012 3 45 1 1 


1 1 


~~||~ Eight 012345 l"~l 


otal Visits: |" 


~\ IZI Total Cases of Gonorrhea: |" | ~~| Total Cases of Syphilis; |~| 




ERSONAL INTERVIEW: Written, Informed Consent Obtained? 1. Yes 2. No |~| 



Month Day Year 



'ATE OF INTERVIEW: 



NTERVIEWER: 



ITY OF INTERVIEW 



STATE: 

IIIZNZI i: 



PLACE OF INTERVIEW: 

1. Hospital 5. Hotel 

2. STD Clinic 6- Hlth Dpt. 

3. Home 7. KSOI Fnd . 

4. PMD Office 8. Pts Office 

9. Other: 



omments : 



213 
Patient GO 1 _ AIDS Project 24 Page 3 

SOCIODEMOGRAPHIC INFORMATION: Let's begin by talking about your place of birth, your age, 

your current residence and the type of work you do. 

PLACE OF BIRTH: 

City \\ C | | | O State |~| |~| AGE: |~| |~| years . 

CURRENT RESIDENCE 

City | || || || I. State |_J | | Comment: 



How many months (total) have you lived in the San Francisco Bay Area? | | | | | | months 
In the past 5 years, how many months have you lived with a lover (s)? | | | | | | months 

USUAL OCCUPATION: What type of work do you usually do? Code:|~| | | |~ 

Other jobs in past 5 years? Code: | | | | |~~| 

EDUCATION: How many years of school have you completed? |~||~l vears 

PERSONAL INCOME: In the past year (1982?), about how much income did you earn? 
Income categories: 1. less than $10,000 3. $20,000 to $30,000 

2. $10,000 to $19,999 k. more than $30,000 | | 

MARITAL STATUS: Have you ever been married (to a woman)? . No. | | times. 

If ever married, are you married now (Circle one)? 1. Yes 2. No Code: | | 

'DLCAL HISTORY: The next set of questions concerns your medical history since you 
were first tested for hepatitis in the City Clinic. According to 
the information I have, you were first tested for hepatitis 

on . Today is , so let's focus on all 

the medical problems you have had in the past (difference between 
HBV test month and today) | |j | months. 

In the past _ _ months (above), have you experienced any of the following symptoms: 
Circle as many as apply (Code the number of symptoms circled; if none, code 0)- 

1. Fever lasting more than 7 days 6. Unexpected weight loss 
SYMPTOMS 2. Night sweats (more than 7 days) of 15 Ibs . or more 

3. Swelling of lymph nodes 7. Persistent diarrhea 
Code: at 3 or more body sites '(more than 7 days 

A. Aches and pains (arthralgias or 8. Shortness of breath 
myalgias) for more than 7 days (more than 7 days) 

5. Painful blisters on your skin 9. skin abnormalities, lesions 

Describe Describe 

SYMPTOM ONSET: If respondent has experienced any of the symptoms suggesting 

possible AIDS, ask for the month and year that he first experienced 
the symptom(s). (If no symptoms are reported, code 00 00). 

Month Year 



Patient GO 1 _ AIDS Project 24 Page 4 

In the past months, have you been told by a medical doctor that you have had any of the 

following medTcaT conditions. If you have, please tell me when you were diagnosed. 

MEDICAL CONDITIONS Circle response Code Month Year 

Lymphadenopathy, or enlarged lymph nodes l.Yes 2. No 

Leukopenia, or a lack of sufficient white cells l.Yes 2. No 

Lyrcphopenia, or a lack of sufficient lymphocytes l.Yes 2. No 

Acquired Immunodeficiency Syndrome, or AIDS l.Yes 2. No 

In the past _ _ months, have you ever been diagnosed with any of the following diseases: 
Circle as many as apply (Code the disease: if none, code 00; if more than one, code 12) 

01. Kaposi's sarcoma 07. Cryptococcal infection 

02. Pneumocystis carinii pneumonia 08. Chronic herpes simplex 
DISEASES 03. Toxoplasmosis (encephalitis/brain) 09. Progressive multifocal 

04. Atypical mycobacterial infection leukoencephalopathy 

Code_ 05. Candida esophagitis 10. Cryptosporidiosis 

| || | 06. Disseminated cytomegalovirus infection 11. Other Cancers: Specify 




jKSET DATE FOR AIDS; If the respondent has been diagnosed with AIDS, htonth_ Year 
indicate the earliest date for symptoms of AIDS | | | | | | | | 

Before (ONSET DATE FOR AIDS) or in the past months (approximately 60), 

" have you received any of the f ollowing~~tKe"rapies : 

Circle as many as apply (Code the therapy: if none, code 00; if more than one, code 11) 

01. Systemic corticosteroid therapy 06* Hemodialysis 

THERAPIES 02. Cytotoxic chemotherapy, or 07. Factor VIII or IX concenti 

other immunosuppressive therapy 08* Cryoprecipitate 

Code 03> Hepatitis B Vaccine 09. Blood or packed red cell 
| | | | 04. Hepatitis B Immune Globulin transfusion 

05> Other immune globulins 10. Other blood components 

'Before (ONSET DATE FOR AIDS) or in the past _ months, how many times did yo 

Donate Blood or Plasma |~| |~| times. 

Obtain Dental Care [ | | | times. Reasons: 

Visit a Physician |~| |~| times. Reasons: 

Receive Hospitalization |~| |~| times. Reasons: 

Have Surgery | || | times. Reasons: 



215 
Patient CO 1 AIDS Project 24 Page 5 

Before (ONSET DATE FOR AIDS) or in the past months, how many times were you 

>ated~foT IhYTollowing conditions. If you were treated, please tell me how many times you 
. .e treated in the City Clinic, at a hospital, by a private physician or by someone else: 

OTHER CONDITIONS Times City Clin Hasp PMD Other Comment (Name of hospital, 

physician or other place) 

Amebiasi. ~ ~ ~ ~ 



Giardiasis 

Shigellosis 

Syphilis 

Gonorrhea |_ 

Herpes Simplex 

Herpes Zoster 

Candida Infection 

Id iopathic /Autoimmune 

thrombccytopenic purpura 

In your lifetime, have you ever had any of the following diseases or medical conditions < 
Circle as many as apply (Code the condition: if none, code 00; if more than one, code 15)- 

01. Tuberculosis 08- Lymphocytic leukemia 

LIFETIME 02. Nocardiosis 09. Multiple myeloma 

CONDITIONS 03. Coccidioidomycosis 10. Diabetes mellitis 

04. Lymphoma or reticulum 11. Chronic renal failure 

_Code_ cell sarcoma (brain only) 12. Chronic hepatitis 

| |j | 05. Burkitt's lymphoma 13. Congenital immune deficiency 

06. Non-Hodgkin's lymphoma syndrome 

07. Hodgkin's disease 14. Bleeding or clotting disorder 

HEALTH BEHAVIOR; The next few questions concern some things related to your health that you 
might have done. For these questions, let's focus on a 

FOUR-MONTH 4-month period after you were first tested for hepatitis and during 

CRITICAL PERIOD which you felt normal and healthy. If you have had any of the symptoms we 

talked about earlier (see page 3), then let's talk about the 4-month perio 

Month _Yar_ before you experienced the first symptom. If you have not experienced any 

| || || || | of these symptoms in the past 5 years or so, let's use today's date. Now, 

which date shall we use? 

In the 4-oonth period before , did you: Circle One: Code Comment 

Smoke more than 4 packs of cigarettes? l.Yes 2. No | | 

Drink alcohol more than 3 days per week 

Share a toothbrush with someone? 

Share a razor with someone? 

Share a needle with someone? 

Share douching equipment with someone? 




o 1 1 el 



DRUGS AND SUBSTANCES: The next part of this study concerns the use of certain drugs. The 
first few questions are about drugs you might have smoked, sniffed or swallowed. Later I'll 
ask you a few questions about drugs and substances that can be injected. Before 
' VSET DATE FOR AIDS) or in the past _ _ months, about how many days in an average TonTh 
k .jld you use . . . 

(Note: If never code 00, but if less than once a month, code 1) 

Recreational drug or substance; Days/Month Comment 
Marijuana (including THC, "hash") 
Nitrite Inhalants: Unlabeled bottles 





Nitrite Inhalants: Labeled bottles 
Ethyl Chloride 

LSD ("acid") 
PCP ("angel dust") i~N~l 

^Azphetanines ("speed"), including MDA | || | 

i 
Barbituates ("downers"), excluding 'ludes | || | 

| Quaaludes | | | | 

Cocaine | | | | 

roin (and other narcotics) 



iln the past months, about how many_times have you injected drugs or substances under 
your skin or into your veins? j | | | | | times. 

_If_ respondent has injected a_ drug o_ substance , please specify: | 1 |~ 



How many times have you used needles that were also used by someone else? | | | | 

IF RESPONDENT HAS BEEN DIAGNOSED WITH AIDS, ASK: Since you first noticed a skin lesion or 
were diagnosed (whichever happened first), how many days per month have you used : 

'Nitrite Inhalants: Labeled bottles |~| |~| Nitrite Inhalants: Unlabeled bottles |~~| |~ 

'SEXUAL BEHAVIOR: Now I'd like to ask you some questions about your sexual activities from t 
day you were first tested for hepatitis until the day you first became ill (ONSET DATE FOR 

'AIDS: ) or, if you haven't been sick, until today. Some of these questions may n 

apply to you. For those that do, I'll ask about two time periods: The entire period from 
your hepatitis test until you became sick (or today) and the period of 4-aonths before you 
became sick (or today). 



ENTIRE PERIOD: The entire period before ONSET DATE FOR AIDS (or today) is | || | nontl 

Number of Sexual Partners; Entire period 4-Month Perio< 

How many different male sexual partners? |~| |~| |~~| | | 
How many different female sexual partners? | | | | | | | | 

Total sexual partners? |~| |~| |~| |~| 



217 
Patient CO 1 _____ AIDS Project 24 Page 7 

MALE PARTNERS ONLY: Of your male sexual partners for these two periods, the entire period and 

the 4-month period, about what percent did you meet or have sexual 
contact with in each of the following places? 

Places of Exposure; Entire Period 4-Month Period Specific Places: Code 

Bathhouse. dOO* O O O* _ OO 

Gay Bars and Discos OOO* OCIO* _ OO 

Bookstores and Movie Theatres O O O * OHOOI Z _ OO 

Public Parks and Restrooms |~| |~| |~| I \~\ |~| |~|Z _ |~| |~| 

Other : _ |~ | |~ | |~ 1 1 |~ | |~ | |~ | Z _ O Ol 

Steady and Nonsteady Partners: Of your _ male sexual partners during the entire period, 
and your _ male sexual partners during the 4-month period, how many did you have sexual 
contact with once or twice (that is, one night or a weekend and not again) and how many did 
you have sexual contact with more than twice during these respective periods? 

Entire Period 4-Month Period 

NONSTEADY SEXUAL PARTNERS (Once or Twice) |~| |~| |~| |~| |~| |~| |~| 

STEADY SEXUAL PARTNERS (Three or more nights) ' |~| Q |~| |~| |~| |~| |~| 



of Exposures; Now I would like to ask you about your sexual activities with male 
, .-tners during the entire period, and also during the 4-month period. First we should talk 
about your nonsteady partners and then talk about your steady partners. For these questions, 
let's talk in terms of percentages. The totals for all activities can exceed 100Z if you hav 
different kinds of contacts with your sexual partners. 

Entire Period 4-Month Period 

Sexual Activity Nonsteady Steady Nonsteady Stead 

Orogenital: Your penis in his mouth, with OMOOl* I M II I* I II II I 2 |~l I" 
or without ejaculation on your part. 

Orogenital: His penis in your mouth, with |~| |~| | \% \ || || j j; | || || |% | | |" 
or without ejaculation on his part. 

Anogenital Contact: Your penis in his anus, l~HOOl* I I I II I* I II II I* I I I" 
with or without ejaculation on your part. 

Anogenital Contact: His penis in your OOl~l* l"~l l~~l l~"l* l~ll~ll~~l* f~l I" 
anus, and he ejaculates in your rectum. 

Anogenital Contact: His penis in your anus, Ol Ol Ol Z I II I I I* I II II I* I M" 
but he does not ejaculate in your rectum. "~~ 

Oroanal Contact: Your tongue in his anus. [~~| [ || |j | || II I j I II 1| |j | | |' 
oanal Contact: His tongue in your anus. [' | | || | j; | 1| 1| I j I II II |x | j [' 

Fisting: Your hand or fist in his rectum. I I I I I IT I II II I* I II I I |t I II 

1 * i- i I i * i i i i i i * i i i i i i " I I i 

Fisting: His hand or fist in your rectum. I II II IT I II II I? I II I I |y I II 

1 * i i i i * i i i i i_ _i * i i i i i i " \ i i 



patient GO 1 



218 
AIDS Project 24 



Page 8 



PARTNERS: If no female partners during the entire period, check here and go to ALL . 
SEXUAL PARTNERS. If any female partners, say "Now let's taTT about female 
sexual partners during the entire period since you were first tested for 

hepatitis. Of your female sexual partners during the entire period, how 

many did you have sexual contact once or twice (but not again), and how many 
did you have contact with more often?" 

Nonsteady female sexual partners during the entire period: |~| |~| |~l 
Steady female sexual partners during the entire period: Q |~| 

ypes of Exposures: For your nonsteady female partners, then your steady female partners, how 
ften did you engage in each of the following kinds of contact: 



Sexual Activity 

aginal Intercourse: Your penis in her vagina, 
with or without ejaculation into her vagina. 

nogenital Contact: Your penis in her anus, 
with or without ejaculation into her rectum. 

roanal Contact: Your tongue in her anus, 
roanal Contact: Her tongue in your anus. 
Lsting: Your hand or fist in her rectum. 
Isting: Her hand or fist in your rectum. 



ENTIRE PERIOD ONLY 

Nonsteady Steady 

ooo* ddd* 

ddd* ddd* 

ddd* ddd* 

cidd* ddd* 

ddd* ddd* 

ddd* ddd* 



LL SEXUAL PARTNERS IN THE ENTIRE PERIOD: Just a few more questions about your sexual 
- :tivities with all of your sexual partners during the entire period (before ONSET OF AIDS, 
it) after you were first tested for hepatitis. 

How many sexual partners paid you money or did you pay money? | || || | partners. 

How many of your sexual partners used drugs intravenously? | || || | partners. 

jj How many of your sexual partners were from Haiti or Africa? |~| |~| |~| partners. 



How many times during or following sexual contact did you 
notice penile or anal bleeding, including blood in 
your stool? 



I_II_M_I Partners 



How many of your sexual partners had similar bleeding during | || || | partners. 

or immediately following sexual contact with you? 

3MMENTS: Before we move on to talk about your travel outside of the Bay area, are there anj 
ther aspects of your sexual activities for us to talk about? 



219 
Patient GO 1 AIDS Project 24 Page 9 

TRAVEL: For the entire period since you were first tested for hepatitis, how many days 
have you spent in each of the following places. If you have spent any time in 
in any of the places I name, please tell me how many different sexual partners 
you had while there (or from there, If you know that your partner lived there). 

Pi ace Day* Partners 

New York City (including Fire Island) |~| O O O O I ' 

Los Angeles (including Laguna Beach) |~| |~| |~| O O I ' 

Miami (including Key West and general area) |~| O O O IO O! 

Haiti and/or Dominican Republic | | | | | | | | | | | I 

Other Carribean Country : I || || | | || I I I 

Mexico, Other Central or South American | || || | | || || | 

Japan, Other Asian Country: LJ LJ LJ l~~l l~l l"~l 

African Countries; | || || | | || || | 

European Countries; | || || | | || H I 

NZW YORK CITY: If respondent had visited New York City, how many times did he visit: 

Place Times 

The Mineshaf t |~| | | | | 

St. Mark's Bathhouse |~| |~~| |~l 

Everhard Bathhouse | | | | | | 

The Loft (on 22nd St or in Triangle Bldg.) l~l l~~l l~l 

Backroom of any Bar: | || || | 

KNOWN CASES: How many people do you know (or have you known) who have been diagnosed 
with Kaposi's sarcoma, Pneumocystis carlnii pneumonia or other 
opportunistic infections associated with AIDS? If you know any, how many 
have been your sexual partners since you were first tested for hepatitis, 
and how many have shared needles with you? 

Number of cases that respondent knows by name: | | | | 

Number of cases who have been sexual partners: | | | | 

Number of cases who have shared needles with you: | | | | 



patient GO 1 AIDS Project 24 rage iu 

ri 220 



SEXUAL PARTNERS: At this time, we believe that AIDS may be caused by an infectious agent. Th 
agent may be spread from one person to another by sexual contact. Therefore 
I'd like to ask you about your sexual partners since you were first tested f 
hepatitis. To distinguish one from another, it would help if we could ident 
each by name. However, neither you nor your sexual partners will be identif 
by name in our statistical studies or research reports. Can we now talk abo 
your sexual partners, beginning with those who you think have (or might have 
AIDS? 

Residence First Exposure Last Exposure Total 
Partner AIDS Case No. (Circle One) Code Month Year Month Year Exposure 



OOOO 1 ' 5 2- NYC 3.0ther|~| |~ | |~ | |~ | |~ | |~| |~ | |~ | |~ | |~ | |~ | 



2- _ |_||_||_Ji_|l.SFO 2.NYC 3.0therd DOOO dddd dd 

3- _ Cl O d CU-SFO 2. NYC 3. Other d Q Q Q Q Q |~ | |~ | |~| Q |~ | 



4- _ CIOCICU- SF 2.NYC 3.0therd dddd 0000 dd 

5- _ |~||~|| 1| ll.SFO 2.NYC 3.0ther| | dddd dddd dd 

6- _ |~|| 1C lOl.SFO 2.NYC 3.0therd dddd dddd dd 
< _ HI O O CU- SFO 2- NYC 3. Other |~ | |~ | d O O d d d O O d 



8- _ OOOd 1 '^ 2-NYC 3-Otherd OOOO O O O O OC 

9- _ Cl O O CU- SFO 2-KYC 3. Other |~ | d O O O O O O O O C 

SUMMARY: Number of Sexual Partners Identified by Name: |~| | | |~| 

Future Research: In the future, we might be interested in having you and other patients loo 
list of names to see how many names you know and how many^of the named persons were sexual 
partners. The list would include some persons with AIDS, 'some without AIDS, and some fictit 
names made out of names found in a telephone book. If we created such a list and showed the 
to you and other patients, would you consent to having your name included on the list? 

C 
Circle One: 1. Yes, include ay name. 2. No, do not include my name. | 

'lo.NCLUSION: Code 

Just a few more questions about your family and friends. | _ | 

Are your parents or grandparents from Italy (Circle One): l.Yes 2. No 

Code 

Did your parents or grandparents, or any of your brothers or sisters, | _ I 
ever have cancer (Circle One): l.Yes 2. No 

Code 

Other than those with Kaposi's, do any of your friends have cancer? | _ I 
Type of cancer: _ l.Yes 2. No 



Attachment 4: Patient Information Sheet 

CITY AND COUNTY OF SAN FRANCISCO 

DEPARTMENT OF PUBLIC HEALTH 

San Francisco City Clinic In cooperation with the: 

356 Seventh Street Centers for Disease Control 

San Francisco, California 94103 Atlanta, Georgia 30333 

Risk Factors for AIDS 

Why this study? 

Acquired immunodeficiency syndrome (AIDS) is a very serious and 
growing problem in San Francisco. Like hepatitis, AIDS may be 
caused by a virus. Like hepatitis, AIDS may be transmitted from 
person to person by sexual contact or exposure to blood. The 
cause of AIDS is unknown and there is no medical cure, but there 
is potential for prevention. 
What can I do? 

We are seeking men who participated in earlier studies of 
hepatitis at the San Francisco City Clinic. Participants in 
earlier studies of hepatitis greatly contributed to our 
understanding of hepatitis. Now we can offer susceptible 
persons a safe and efficacious vaccine to prevent hepatitis B. 
Once we better understand the cause of AIDS and how it is 
spread, we will be better able to stop its course. If you are 
interested in participating in this study of AIDS, please 
contact Paul O'Malley (Telephone 415 864-8100, ext. 41 or 42) 
Why should I participate? 

You will learn about AIDS, be tested, and be examined for signs 
of AIDS. You may benefit the Community. At present the sexual 
practices which are most likely to transmit AIDS are not clearly 
defined, therefore no reasonable counseling can be offered those 
at risk of acquiring or transmitting AIDS. 
What is involved? 

Participation requires signing an informed consent form, 
answering a confidential medical and sexual practices history, 
getting blood and urine tests to determine your current status, 
being examined by a doctor and, possibly, an appointment for 
follow-up testing at another time in the future. 
What about my test results? 

You will be informed if you have evidence of AIDS. 
What if I am found to have evidence of AIDS? 

You will be given a physical examination by one of City Clinic's 
physicians, have additional tests and given medical referral if 
indicated. 
What if I change my mind? 

Participation is voluntary. If you refuse to participate in 
this study of risk factors for AIDS, the medical care offered 
you by City Clinic will in no way be affected. 
What about confidentiality? 

Any information you voluntarily offer will be held in 
confidence. Study materials and results will be identified by 
numbers only, not by names. 

Whatever your risk of acquiring AIDS may be, it will be the same 
whether you choose to participate or not. 

Still have questions? 

We will be happy to talk to you. Just call Paul O'Malley: 415 
864-8100, ext. 41 or 42. 



222 



Attachment 5: Initial Letter 

CITY AND COUNTY OF SAN FRANCISCO 

DEPARTMENT OF PUBLIC HEALTH 



San Francisco City Clinic 
356 Seventh Street 
San Francisco, California 94103 
864-8100 



In cooperation with the: 
Centers for Disease Control 
Atlanta, Georgia 30333 



Date; 



Addressee : 



Dear 



The San Francisco Department of Public Health, in cooperation with the 
Centers for Disease Control, is conducting a study of risk factors for 
acquired immunodeficiency syndrome (AIDS). We are seeking people who were 
tested for hepatitis at City Clinic. Our new study is described In the 
enclosed patient information sheet. We hope that you will be interested in 
participating in this important study. 

Whether you choose to participate or not, please complete the bottom half 
of this letter and then return the entire letter in the preaddressed envelope 
I have enclosed. If you decide to participate, I'll be back in touch with you 
shortly after I receive your response. 

Thank you for your interest in our previous research project and your 
response to this request. 

Sincerely yours, 



Paul O'Malley 

Cohort Study Coordinator 



Please check your response and state your preferences. 
Dear Paul , 

| | I am Interested in participating. Please call me at 
or write to me at 



for an appointment. It would be best for me if you could arrange to see me on 

(day): __, at (hour) . Other 

conditions : 



| | I am not Interested in participating in this particular study. 

Don't forget to return the entire letter in the preaddressed envelope I have 
enclosed . 



223 



:y-!UNi: TCFICEMCY 






And 



Resource ar.d Referral Lists 



The Jar; 7rancisc3 Depart-ent of Public Health acknowledges 
the following AIDS Services Coordinating Conmittee r.eabers 
for Tiheir cor.rribuiior. to this nar.ua 1: Robert Bolan, M.D., 
3. A. P.M. P., Steven Mehalko, M.D., 7 rank lin Hosrital, 
Pat "orrar. D.P.H., Helan Scheitinger R.H., U.C.S.?., Paul 
Volberding, M.D., S.F.G.H. 



224 
INTRODUCTION 



In recent years, the incidence of rare and often fatal diseases such as Kaposi 
Sarcom?., Pneumocystis Carinii and other opportunistic infections has risen in 
the United States in 24 states and world-wide in seven countries. These 
diseases are a sub-group manifestation of the disease called Acquired Icmune 
Deficiency Syndrome (AITS), which is an impairment of the body's immune defense 
system. The people most effected by these diseases, until quite recently, have 
beer, the gay rale population. Seventy-five per cent of the AIDS patients are 
from the gay male population and Twenty-five per cent of the AIDS patients are 
free the heterosexual and bisexual nale and female populatior.(this group 
includes, i.e. drug users, Haitian refugees and hemophiliacs) are affected. At 
this tine, well over six huncrea^(_fcj_}_diagr^sed caaen havg_Jb_een_ reported 
rationally through the Communicable Disease Center in Atlanta, Georgia, of that 
number, appropriately one hundr^r'tTl 2J_^ cases have been reported in the San 
Trancisco 3ey Area. The rise in these diseases has created questions still 
unanswered by the nedical profession or researchers. Due to the rarity of the 
disoase, the sudden rise in incidence, the high mortality rate end the lack of 
information on the etiology of the disease or the treatment method of choice, 
there is great concern that health service recipients have access to services 
that are knowledgeable, as well as, sensitively give?, to those who have 
questior.3 about and/or symptoms of these diseases. The opportunistic 
infections associated with AII3 are: Kaposi Sarcoma, Pneunocystis Carinii 
Pneumonia, Burnett's and non-Kodgicins lymphoma; meningitis or encephalitis due 
to or.e or more of the following: Aspergillosis, Car.didiasis, cryptococosis, 
cytcmeelovirus, "locardiosis, stror.r/loidosis, toxoplasmosis, zygomycosis, or 
atypical -ycobacteriosis; esophogitis due to Candidiasis, cytomeglo-'irus, 
herpes simplex virus; progressive -ultifccal leukoer.cephalopathy; unusual 
extensive muco cutaneous herpes simplex of trore than 5 weeks: 1) recurrent 
staphlccoccus infections in axillary or groin areas (bullous impetigo' ; 2) 
cry ttosr2Tiiiosis-aiarrr.es ; 1>~) IT? (idiopathic thrombocytopenic purpura' 1 . 
Lymphader.apathy is listed here as a disease for concern and treatment need. 
This disease is identified by lycph node enlargement of at least six months 
duration. It is sometimes considered a warning sign for possible AIDS 
contraction. 

The information cor.tsined in this directory is for use by health care 
providers in deciding the proper referral process and protocol for peorl? -..-iti'. 
symptoms of All? or associated infections. Health oare providers :i;ted 
herein are experienced in treating these diseases and are either the sources 
of, or in contact ;::th, the sources most familiar with the latest treatment 
theories and methodologies used for these complaints. If you have need for 
information not listed in this director;', please call the Kaposi Sarcoma 
Tour.cation at 86^-^376 or the Gay ana Lesbian Health Services Coordinator. 
Denartment of Public Health at 5;5-25-i 1 . 



; 4 -i, t -.., r v / / r-o 

' ' . L-'^ 1 - -. v--\ (_ x ^ i __^. L^ t v 



225 




Fact Sheet for Teaching Classes on AIDS 

This information is based upon a distillate of the knowledge 
accumulated by SFGH, UCSF, UCLA, Stanford, several hospitals in New 
York and the combined efforts of the AIDS Task Force at the Center for 
Disease Control in Atlanta, Georgia. There are no other authorities to 
turn to for more or better information. Continuing communication 
between all these Centers provides the best available knowledge for 
all. 

I. What is A.I.D.S? 

Acquired Immuno Deficiency Syndrome is a disease of previously 
healthy people who for some reason develop diseases seen only in 
the immunodef icient . The deficiency appears to be permanent and 
is not explained by other known immune defect diseases. While 
there are several theories as to what it is, the one felt to be 
the Most likely is that it is a new virus, not previously seen. 

II. Who is at risk? 

A. 4 high risk groups 

homosexual and bisexual men (75% of cases) 
heterosexual men, women, and children (25% of cases) 

hcmophi 1 iacs 

IV drug abusers 

Hai tians 

5% unknown risk factors 

B. Hospital workers have not acquired AIDS unless also a member 
of a high risk group (after more than three years experience 
in New York City in which no precautions were taken in the 
hospital for about the 1st 2 years) 

C. >1100 cases in the US since late 1979 
>l/2 States in US have 1 or more cases 
>13 foreign countries 

affects all races and all ages (none identified over the age 
of 60)and both sexes 

III. How is it transmitted? 

A. From a long list of epidemiological questions given to AIDS 
patients, it appears that the route of transmission is 
most like Hepatitis B 

*1. Blood end other secretions 
*2. Sexual contact 

3. Food does not appear to be a source - otherwise it 
would have spread beyond the high risk groups 

4. Air does not appear to be a source - otherwise it 
would have spread beyond the high risk groups. 

5. Large doses or repeated exposures may be necessary 
as with many other diseases since there are people 
who have been exposed who have not come down with 
it. 



226 



B. Incubation period seems to average 1 1/2 - 2 years 

C. Like hepatitis it seems to be communicable during incubation 
and before symptoms occur. 

IV. Immune System Defect 

A. Characteristic of most AIDS cases are elevation in some 
immunoglobulins and abnormal T lymphocyte levels. 
Specifically, the Helper : Suppressor ratios are affected. 

Normal ratios are 1.5-2 Helper cells for every 1 
Suppressor cell. 

AIDS patients average 0.5 helper cell per 1 Suppressor 
cell. 

This test _i_s not a test for AIDS . Some AIDS patients do 
not have abnormal levels, especially early on. Nany 
people have abnormal ratios and do not have AIDS. 
Nany diseases including most viruses and other 
infectious diseases cause temporary abnormalities. 
The difference with AIDS is the seeming permanence of 
the defect. THIS TEST IS NOT DIAGNOSTIC NOR WILL IT 
PREDICT WHO IS SUSCEPTIBLE. 

V. How is Diagnosis Made? 

The patient must have symptoms and be diagnosed with sn 
opportunistic infection that does not normally affect 
healthy people. Or they must have biopsy proven Kaposis 
Sa rcoma (biopsy is necessary to be sure this is not some 

other dermatologic problem). 

T Lymphocyte studies are not diagnostic. 

If no other explanation for the immunosuppression can be 
found, a tentative diagnosis of AIDS can be made. 

VI. How is it Treated? 

Kaposis (KS) is treated with an experimental protocol using 
Interferon. There has been success in gaining remission in 
some cases but in none have the immune defect corrected 
i tself . 

Pneumocystis carinii pneumonia is treated with high dose 
Septra or Pentamidine with success in some cases but without 
regaining normal immune system function. 



These are examples of treatment of clinical illnesses which 
some patients have but are not actual treatment of AIDS (a 

t rar.smi t table egcnt that causes immunosuppression). There is 
no Known treatment for AIDS itself. 



J 

227 



Other clinical illnesses are treated According to the 
specific illness, frequently fungal infections. 

VII. Diseases seen in these patients: 

The diseases seen are old diseases seen before but which do 
not normally occur in healthy people 

Pneumocyst i s 

Aspergi llus 

Cryptococcus 

Toxoplasmosis 

Mycobacter i urn avium 

or are extreme manifestations of diseases which can affect 
otherwise healthy people 

massive Herpes simplex which does not go away 

Candida pharyngitis and esophagitis 

Herpes zoster 

widely disseminated Cy tomegalovi r us (CMV) 

f*.ost of the above are ubiquitous organisms found everywhere 
in nature ano may be in all of our bodies right now. They 
become a threat when the inur.une system does not function. 
Acc',:irinq one cf thest organisms does no t give you A. I D 5 . 
One must be immunosuppressec in orcer to be susceptible to 
one of these opportunistic infections. 

VIII. CMV (Cytomegalovi rus) 

CMV is a ubiquitous organism which is passed from one person 
to another by contact with body secretions. The two most 
common ways of acquiring it is through sexual contact and 
intimate contact with children under the age of 5. In 
healthy people this does not often cause symptoms. 
Occassionally it causes a form of mononucleosi s . When 
acquired from transfusions it may cause a form of hepatitis. 

50% of the general population have already had CMV as 
evidenced by antibody. However, only about 1-2% are 
excreting it in the urine or semen. In certain populations 
the excretion rate is higher (children under the age of 5 up 
to 51% in some studies, renal transplants, Dialysis 
patients, Oncology patients, tht Gay population, pregnant 
women). Having antibody to CMV does not convey immunity. 

The AIDS patients, in our experience, have a high rate of 
excretion of CMV late ji_n the course o_f their illness. This 
is frequently found in the lungs. Since it is rare to have 
anyone with CMV pneumonia, there aren't good studies to show 
the transmissibility of CMV by this route. Therefore, we 
have no way of knowing at this time if this is an important 
route of spread from patients. 



228 



X. Infection Precautions for Outpatients 

1. AIDS Clinic - Gloves are used for any contact with blood or 

other secretions. Masks are worn by patients who are 
coughing or health worker if patient must be unmasked for 
procedures or examination. 

2. AIDS patients in other clinics may be seen as above. 

3. Emergency Room patients presenting with symptoms compatible 

with AIDS may be seen as above. Care should be taken to 
screen these patients with sensitivity. Do not forget that 
25% of AIDS cases are not gay and that the focus should be 
on careful handling of blood and secretions from ell 
patients rather than selecting out one high risk gToup. 

XI. V.ays of Approaching Fear of the Unknown 

Although the t r erisrr.i ss i ble agent of AIDS is not known, we 
have quite a bit of e pidemi olog ic information about how it 
is spread. The more people are able to focus on what we know 
and use basic proven Infection Control practices not only in 
the care of AIDS patients but in all patients, the more 
feeling of control people are likely to feel. There are only 
a certain number of ways disease can be spread and only a 
certain number of technics which have been shown to be 
effective. Anything beyond what we are doing now is probably 
window d ress ing . 

When teaching classes it is important for the instructor to 
be aware of his/her own anxieties so that one can make the 
conscious choice to give useful information rather than make 
statements that are expressions of free-floating anxiety. 
With useful information you can have control of the fear. 
With free-floating anxiety, the fear controls you. 

XII. Employees Who Fear They May be More Susceptable 

The two most common expressions of this are Gays who feel they 
may be more susceptible because they have heard that many 
Gays have abnormal Helper : Suppressor ratios and people who 
have special health problems. 

1. An abnormal H:S ratio does not prove greater susceptibility 
because the cause of that abnormal ratio is not known. It 
may be an expression of a recent viral illness, for example. 
Recent CN:V infection (very common in gay population) causes 
up to 6 months of some degree of immunosuppr ess i on but is 
not permanent. 



229 



The importance of CMV transmission in the hospital setting 
relates to acquisition by pregnant women since this is a 
cause of birth defect in the children of 40% of women who 
acquire it during pregnancy. 



IX. Infection Precautions for In Patients 

Precautions Rationale 



1. Private Room 



Blood (a.id other secretions) 

pr tcaut ions : 

Wear gloves for all blood 
and other secretion contact 



This is for the protection 
of the patient who is more 
susceptible than most, to 
other infections. 



Blood 
to be 



and secretions appear 
the major source 



Wear gloves for starting 
or drawing bloods 



IVs 



Baker Box or other puncture 

proof box in room for needles, 

which should not be oroken 
or recapped 

Handv/ashing 



Gowns need only be worn where Viral diseases without 
heavy contamination is expected, excretions do not get 



This may mean ICUs, care of 
terminally ill, procedures, 
patients with massive lesions. 

Masks to be worn by health work 
ers if patient has lung involve 
ment and is coughing or intubated 
Mask to be worn by patient out 
side room when coughing. 

Pregnant women should not have 
direct contact with excreters 
of CMV. For practical purposes 
we assume AIDS patients to be 
excreting. Based on Virus Lab 
findings, we expect excretion 
to occur in later illness rather 
than at early diagnosis. 



transmitted by way of 
clothing . 



THERE IS NO EVIDENCE THAT 
A.I.D.S. IS TRANSMITTED 
BY THE AIR. Masks are 
to prevent spread of 
CMV primarily. 

It is common practice 
in hospitals to not 
assign pregnant women 
to known excreters. 
However, should a nurse 
later find that she is 
pregnant, having taken 
the prescribed precau 
tions will give her more 
protection than she will 
have from her sexual 
partner or preschool 
children. 



230 
CURRICULUM VITAE 

Appendix D 

Selma K. Dritz, M.D., M.P.H. 

Office: 

101 Grove Street 

San Francisco, CA 94102 

(415) 558-4046 

Birthdate: 29 June 1917 
Place of birth: Chicago, Illinois 
Citizenship: United States 
Education and degrees: 

University of Illinois 1939 - B.Sc. in Medicine 

University of Illinois 1941 - M.D. 

University of California, Berkeley 1967 - M.P.H. 

Honors achieved: Alpha Omega Alpha, Illinois 1941 
Post graduate training: 

Cook County Hospital, Chicago - Internship 1941-42 

Cook County Children's Hospital, Chicago - Residency 1942-44 

Cook County Contagious Disease Hospital, Chicago - Chief Resident 

1944 
University of California School of Public Health, Berkeley, CA 

1966-67 

Professional experience: 

Illinois State Health Department, Springfield - Pediatrics 

Consultant 1946-47 

Private practice, pediatrics, Chicago - 1945-46 
San Francisco Department of Public Health - 1967-1984 

Assistant Director, Bureau of Disease Control, and Chief, 
Division of Occupational Health, concurrent 

Appointments : 

University of California Medical School, San Francisco, 1972 to 
present, Consultant, Department of Ambulatory and Community 
Medicine 



231 

Governor's Industrial Safety Conference, California, 1970-73 
San Francisco Medical Society, 1970 to present: 

Technical Advisory Committee, Air Quality Maintenance Program 
California State Task Force on AIDS, 1982-84 

Professional memberships: 

San Francisco Medical Society 

California Medical Association 

American Medical Association 

Northern California Public Health Association 

American Public Health Association 

California Academy of Preventive Medicine (Pres. 1981) 

American College of Preventive Medicine 

Western Industrial Medical Association 

American Occupational Medical Association 

American Society of Tropical Medicine and Hygiene 

Publications : 

Cappucci, DT; Emmons , RW; Mullen, DA; Dritz, SK; Garcia, JP. 
"Unusual Laboratory Exposure to a Rabid Skunk." J. Amer. Veter. Med. 
Assn. Vol. 161, No. 6. 1972. 

Morbidity and Mortality Weekly Report. Shigellosis - California. 
Dritz, SK. Vol. 21, No. 11. 1972 

Morbidity and Mortality Weekly Report. Salmonella typhimurium 
Outbreak in a Newborn Nursery - California. Dritz, SK. Vol. 23, No. 
11. 1974. 

Dritz, SK. "Lead Levels in San Francisco Children." New England J. 
Med. Vol. 290, No. 12. 1974. (letter) 

Dritz, SK. "Shigella Enteritis Venereally Transmitted." New England 
J. Med. Vol. 291, No. 22. 1974. (letter) 

Dritz, SK, & Braff, EH. "Sexually Transmitted Typhoid Fever." New 
England J. Med. Vol. 296, No. 23. 1977. (letter) 

Dritz, SK; et al. "Patterns of Sexually Transmitted Enteric Diseases 
in a City." The Lancet. Vol. 11,. No. 8027. 1977. 

Calin, A; Kaslow, R; Simon, D; Ryder, R; Kaye, R; Dritz, S. Reiter's 
Syndrome (RS) and the Sero-epidemiology of Shigella. The Heberden 
Society. September 1978. 



232 

Owen RL, Dritz SK, Wibbelsman C. Venereal aspects of 
gastroenterology - Medical staff conference, University of California 
San Francisco. West J Med 130:236-246, Mar 1979. 

Dritz SK, Goldsmith RL: Sexually Transmissible Bacterial, Protozoal 
and Viral Enteric Infections. Comprehensive Therapy 6(1): 34-40, 
1980. 

Dritz SK: Medical Aspects of Homosexuality. New England J. Med. 
Vol. 302: 463-464 (January 24), 1980. 

Spinelli, JS, Ascher, MS, Brooks, DL, Dritz, SK, Lewis, HA, Morrison, 
RH, Rose, L, and Rupanner, R. Q fever crisis in San Francisco: 
controlling a sheep zoonosis in a lab animal facility. Lab Animal: 
pp. 24-27, May 1981. 

Dritz, SK: Medical Problems in Homosexual Men. West J. Med. 1982, 
Vol. 136: 54-55. 

Conwill, DE, Werner, SB, Dritz, SK, et al. Legionellosis. The 1980 
San Francisco Outbreak. Am Rev Respir Dis 1982; 126:666-669. 

Amroann, A, Wara, DW, Dritz, SK, et al. Acquired Immune Deficiency 
Syndrome in an Infant: Possible Transmission by Means of Blood 
Products. Lancet, 30 April 1983. 

Jaffee HW, Choi K, Thomas PA, et al. National Case-Control Study of 
Kaposi's Sarcoma and Pneumocystis carinii Pneumonia in Homosexual 
Men: Part 1, Epidemiological Results. Annals of Internal Medicine, 
1983: 99:145-151. 

Ammann AJ, Dritz SK, Volberding P, et al: The Acquired Immune 
Deficiency Syndrome (AIDS) - A Multidisciplinary Enigma-Medical Staff 
Conference, University of California, San Francisco. West J Med 1984 
January; 140:66-81. 



Abstracts : 



Sexually Transmitted Enteric Diseases in San Francisco. American 
Public Health Association Annual Meeting. Washington DC, November, 
1977. 

Sexually Transmitted Enteric Diseases. California Medical 
Association Annual Meeting. San Francisco, March, 1978. 

Infectious Disease Incidence in San Francisco, 1977. American 
Academy of Family Physicians Annual Meeting. San Francisco, April 
1978. 



233 



Illness and Injury Prevention in Day Care Centers. Maternal and 
Child Health Section Pre-APHA Conference. University of California 
School of Public Health. American Public Health Association Annual 
Meeting. October 1978. 

Sexually Transmitted Diseases Study Group. National Institute of 
Allergy and Infectious Diseases, National Institutes of Health, 
Washington, DC, January 14-15, 1980. 

Sexually Transmitted Diseases-Treatment Guidelines 1982, CDC: 
Morbidity and Mortality Weekly Review, Supplement. Volume 31 Number 
25, August 20, 1982. 



I 



234 Appendix E 

Silverman materials 
documents relating to 
the closing of the 
bathhouses 
DECLARATION OF MERVYN F. SILVERMAN, M.D. 

I, Mervyn F. Silverman, M.D., do hereby make the following 

3l 

declaration in support of the Application for a Temporary 

Restraining Order and Order to Show Cause Re: Preliminary 
Injunction: 

1. I am now, and have been since May 2, 1977, the duly 
appointed and acting Director of the Department of Public Health 
of the City and County of San Francisco. 

2. In 1960, I received a Bachelor of Science Degree with 
honors from Washington and Lee University in Virginia. I 
received my M.D. from Tulane University in 1964 and a Masters 
Degree in Public Health from Harvard University in 1969. From 
1969 to 1970, I served as Assistant to the Commissioner at the 
Federal Food and Drug Administration and was Director of Consumer 

Affairs for the Food and Drug Administration from 1970 to 1972. 

i 
From 1972 to 1977, I served as the Director of Health for the 

Department of Community Health of Witchita Sedgwick County, 
Kansas, where I supervised a public health staff. A copy of my 

curriculum vitae is attached as Exhibit 1 hereto and incorporated 

i 
herein by reference as though fully set forth. 

3. As San Francisco's Director of Public Health, I have 
been responsible for directing the City's response to the 
epidemic of Acquired Immune Deficiency Syndrome ("AIDS"). Early 
in 1981, I first became aware of a strange disease almost 
exclusively striking homosexual males in several large urban 
centers. Since I believed that San Francisco, with its large 



235 



homosexual population, was certain to be particularly hard hit, I 
2 directed my staff to study all cases of AIDS In San Francisco in 

o 

order to gather information on risk factors and behavioral 
patterns of the affected population. I initiated this study well 

before the State of California required the reporting of this 

6 

disease. 

4. The study performed by my staff was designed to 

a 

assist me in formulating public health policies to prevent the 

9 

spread of AIDS in San Francisco. From the information I 



10 
11 

12 

13 

14 

15 

16 

17 

18 

19 

20| 

21 

221 

23 

24 

25 

26 



obtained, I quickly concluded that AIDS is a uniquely virulent 
disease. The incidence of this disease in the homosexual male 
population is alarmingly high. In my opinion, the unprecedented 
rate of increase in new cases and the parallel growth in the 
number of people dying each day (now almost one per day and 
expected to be two per day within the next twelve months), 
combined with the fact that there is no cure for the disease and 
virtually all who contract AIDS are dead within four years, makes 
this disease a tragedy of unparalleled dimensions. San Francisco 
is the focal point of this tragedy. We have in San Francisco the 
highest per capita incidence of AIDS of any urban center in the 
world. 

5. AIDS is a horrible, protracted, painful disease that 
debilitates its victims well before they die. Treatment is 
costly and ultimately ineffective. There is no known cure. The 
disease has a long incubation period, presently estimated to be 
from six months to five years. This long incubation period means 



236 



that those who have contracted the disease may experience no 

2 

clinical symptoms for months or even years while they may be 

3 

carriers capable of spreading the disease. The epidemiological 

4 

and etiological studies I have seen indicate that AIDS is caused 

by a virus. All the available evidence compels the conclusion 

6 

that the disease is primarily sexually transmitted. The evidence 

further shows that there is a direct correlation between the 

8 

number of male homosexual sex partners someone has and the 

9 

likelihood he will contract the disease. 

6. As a public health officer, I have regularly studied 
epidemics and their effects on the population. As the AIDS 
epidemic has unfolded in several locations in the United States, 
I have come to realize that this disease has reached epidemic 
proportions in the affected population of homosexual males. An 
informed medical opinion leads me to conclude that we can have no 
reason to believe that the disease could not spread outside this 
population group. 

7. Based upon all of the facts before me, I concluded 
that official public health action was required. In view of the 
sensitive nature of public intrusion into matters of personal 
privacy and the need to maintain rapport and credibility with the 
affected population, I initially directed a concentrated and 
comprehensive educational program designed to inform the affected 
population and businesses catering to high-risk behavior. 
Through this program, I sought to educate the community regarding 
the nature of AIDS, the dangers of the disease, and the role of 



237 



sexual transmission in the spread of the disease. In particular, 

2 

the educational program urged homosexual males to avoid engaging 

in sexual activities that involve the exchange of body fluids. 

4 

It further stressed the importance of avoiding multiple sexual 

contacts because of the enhanced risk of contracting the disease 

6 

associated with such activity. 

8. Our educational efforts proved successful in part. 

g 

For example, we have always considered gonorrhea in the 

9 

homosexual community a reliable measure of the degree of sexual 



10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 



activity amongst homosexual males. By that measure, our 
educational efforts have succeeded in that the incidence of 
gonorrhea has declined. However, the rate of new AIDS cases and 
the number of deaths a month have sky-rocketed. Even if 
eventually there is a decline in the rate of the spread of AIDS 
such that it declines to the present levels of gonorrhea cases, 
that level would still oe unacceptably high. In establishing 
public health priorities, we can deal with the incidence of 
gonnorhea in the affected population because gonorrhea is a 
non-fatal and easily-cured illness with a short incubation period 
and relatively few severe complications in most cases. However, 
the same policy is unacceptable when we are confronted with a 
fatal, incurable disease, especially one with such a long 
incubation period. 

9. In addition to the study done by my staff, the 
Department of Public Health contracted with Leon McKussick to do 
a study on the behavior of homosexual males following our 



238 



1 
2 
3 
4 

5 

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16! 

I 
17! 

i 
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educational program. We learned that many members of the 
community, when informed of the risks, changed their practices to 
avoid unsafe sex. However, a significant number of those 
surveyed have disclosed that although fully informed of the 
dangers involved they have chosen to continue engaging in 
high-risk sexual activities. 

10. Further,- our studies have shown that in addition to 
multiple sexual activity being a high-risk behavior, certain 
commercial enterprises commonly known as bathhouses and sex 
clubs, but which also include book shops and certain other types 
of f acilitities, foster, promote, encourage and facilitate these 
multiple sexual contacts. An individual so inclined who may be 
able to have one or two sexual contacts in public surroundings 
may be able to have eight or ten, or even fifteen to twenty, 
contacts in a bathhouse setting. Hence, bathhouses and similar 
commercial facilities have been shown to be uniquely adapted to 
one of the highest risk behaviors to wit: multiple sexual 
contacts . 

11. As a public health officer, I consider it my duty to 
fashion and implement public policies designed to discourage and 
bring to an end commercial enterprises that involve exploitation 
for profit of an individuals' willingness to engage in 
potentially fatal forms of recreation. AIDS is killing young 
people in the prime of their lives, many of whom are hard working 
and valuable members of our community. The tragedy of their 
deaths deprives the community of their industry and creativity 



239 



and burdens the public fisc with the enormous charges of treating 
the plethora of AIDS-related ailments. In my opinion, although 
sexual activity is a matter of individual privacy, when that 
activity takes place in a commercial setting the government has 
the prerogative and the duty to intercede and halt the operation 
of businesses that foster, promote, encourage, and profit from 
individual activities that threaten to spread virulent disease. 
12. In addition to our educational activites, I and 

o 

members of my staff have urged owners and operators of 
' bathhouses, sex clubs, book stores and other establishments where 

high-risk multiple sex has been prevalent to change their 
.operations and assume responsibility for the health and safety of 

their customers by preventing them from engaging in dangerous 
' sexual activities. Recent inspections have led me to conclude 

that some businesses indeed have changed their practices, and in 



16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 



those facilities there is a conscious effort on the part of the 
management to discourage unsafe sexual practices amongst their 
customers. However, some businesses have refused to make any 
significant changes in their operations. They continue to 
encourage and facilitate multiple sexual contacts. 

13. I have determined that the AIDS epidemic has reached 
such proportions that strong public health measures must be 
taken. The continued operation of businesses that encourage, 
facilitate, and profit from multiple sexual contacts, directly 
linked by all scholars with the transmission of AIDS, constitutes 
a hazard to the public health. As San Francisco's public health 



2AO 



officer, I am duty bound to take those steps I deem necessary to 
prevent the tragic waste of human life, the diversion of public 
resources for the treatment of this insidious disease, and the 
continued infection of innocent people in places of business 
operating primarily for the purpose of profiting from this 
commerce in death. Therefore, I have determined that these 
businesses must be closed and I have ordered the same. 

I declare under penalty of perjury under the laws of the 
State of California that the foregoing is true and correct. 

Executed on October _/_, 1984, at San Francisco, 
California. 





F. SILVERMAN, M.D. 

*~s 



4206D 



. f 



64^- 

- : 0) 



241 

- i ! 



_/ .-. t- x -- - v 

ENDORSED 

FILED 

Can Fitnc.ico County Supafici Court 

DEC 24 1984 

DONALD W. DICKINSON, Clerk 

RV- Bemie Fabro _ 

.Deputy Clerk 



SUPERIOR COURT OF THE STATE OF CALIFORNIA 
IN AND FOR THE CITY AND COUNTY OF SAN FRANCISCO 

DEPARTMENT EIGHT 



PEOPLE OF THE STATE OF ) No . 830-321 

CALIFORNIA ex rel . GEORGE AGNOST, ) 

City Attorney, et al. , ) / MODIFIED 

) v PRELIMINARY INJUNCTION 

Plaintiffs, ) 

vs . ) 

IMA JEAN OWEN, et al. , ) 

Defendants. ) 



IT IS HEREBY ORDERED that Defendants, and each of them, 
their agents, employees, tenants, lessees, successors and assigns 
be enjoined and restrained from renting or operating any and all 
private rooms within their premises other than those which are 
licensed to be operated as hotel rooms pursuant to Section 160 of 
Part III of the San Francisco Municipal Code; provided, however, 
that those Defendant establishments which are licensed as massage 
parlors pursuant to Article 27 of the San Francisco Police Code 
may allow the occupation of one and only one room per 
establishment by a licensed masseur or masseusse for the purpose 
of giving massages. 



1 

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' 242 



IT IS FURTHER ORDERED that each operator-Defendant shall 
provide employees (hereinafter, "monitors") for the exclusive and 
sole purpose of observation of activity on their premises. Such 
monitors shall survey the entire premises every ten minutes. The 
number of such monitors shall be determined according to the 
following formula: (a) For the Defendant bookstores, one 
monitor for each floor or portion of a floor primarily devoted to 
video/movie booth arcades, and one monitor for any other floor or 
portion of a floor open to patrons, other than areas primarily 
devoted to the sale of periodicals.; (b) For the Defendant movie 
theatres, one monitor for any floor or portion of a floor open to 
patrons; and, (c) For all other Defendants, two monitors for any 
floor or portion of a floor open to patrons. 

In the event any operator-Defendant can submit, together 
with a declaration under penalty of perjury, competent evidence 
establishing the average hourly patronage based upon records of 
that operator-Defendant's business during the hours from seven 
p.m. to closing for the three month period commencing on June 1, 
1984 and ending on August 31, 1984, that operator-Defendant nay 
provide one monitor for each twenty patrons according to the 
average hourly patronage of the particular establishment between 
the hours and dates specified above. An operator-Defendant may 
provide monitors according to this formula ten days after 
submitting the declaration and supporting documentation to the 
City Attorney; provided, however, that if the City Attorney 
objects to the declaration and moves the Court for correction, 



-2- 



243 



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ORGE AGNOST 

x 20 CITY MALL 
93* 3313 



the Court shall determine the appropriate formula for monitors. 

Plaintiffs and individual operator-Defendants may by 
stipulated order modify the number of required monitors for any 
Defendant establishment. 

Each operator-Defendant shall prepare a report indicating 
the total number of patrons admitted per day and the number of 
patrons on the premises on the odd-numbered hours from the hour 
of opening until the close of business. Copies of these reports 
shall be served upon the City Attorney once per week during the 
pendency of this preliminary injunction accompanied by a 
declaration under penalty of perjury attesting to their 
accuracy. Said declarations shall be served each Tuesday no 
later that four p.m. and shall cover the seven day period ending 
at the close of business on the immediately preceeding Sunday; 
provided, however, that these patronage reports shall not be 
required of any Defendant establishment that elects to base its 
number of monitors upon the fixed number formula, rather than 
upon the average hourly patronage formula. 

This duty on the part of the operator-Defendants to monitor 
the activity of their patrons upon the premises in no way limits 
or supersedes the authority of the Department of Public Health or 
any other authorized agency or individual to conduct any and all 
inspections deemed necessary. 



-3- 



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15 AGNOST 
' 'Tomnrr 

>1 CITY MALL 
'ISCO iIO2 
>3 J3I3 



244 



The Director of Public Health having defined high risk 
sexual activity as set forth in Exhibit A hereto, IT IS FURTHER 
ORDERED that Defendants shall immediately expel from the premises 
any and all patrons observed engaging in such high risk sexual 
activity. 

In the event that the Director of Public Health, in 
conjunction with the San Francisco AIDS Foundation, determines 
that a definition different than that set forth in Exhibit A of 
this order would be appropriate, he may offer such alternative to 
the Court for its consideration as a basis for modification of 
the preliminary injunction. Should the. San Francisco AIDS 
Foundation and the Director of Public Health fail to agree on a 
definition, the determination of the Director of Public Health 
shall control. 

Each operator-Defendant shall prepare a report of incidents 
where patrons are expelled pursuant to this order. The report 
shall describe generally the circumstances leading to the 
expulsion. Defendants are not required to obtain or report the 
names of individuals expelled. Copies of these reports shall be 
served upon the City Attorney once per week during the pendency 
of this preliminary injunction accompanied by a declaration under 
penalty of perjury attesting to their accuracy. Said 
declarations shall be served each Tuesday no later that four p.m. 
and shall cover the seven day period ending at the close of 
business on the immediately preceeding Sunday. 

IT IS FURTHER ORDERED that the doors to individual 



245 



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3RGE AGNOST 

mr ATTOKNIT 
* ice CITY HALL 
~C.SCO >4t03 
S 3313 



video/movie cubicles, video/movie booths or video/movie rooms be 
modified as follows: for individual video/movie cubicles where at 
least 4 feet of clear space exists in front of a booth, removal 
of the bottom 24 inches of the door shall satisfy the terms of 
this order; where less than 4 feet of clear space exists, removal 
of the bottom 39 inches of the door shall satisfy the terms of 
this order. Defendants shall ensure that no more than one person 
at a time enters an individual video/movie cubicle. 

Should there be a violation of this preliminary injunction, 
Defendants, upon written notice from the Plaintiffs, shall be 
given a five day opportunity to cure such violation. Thereafter, 
Plaintiffs, upon written notice to the Defendants, may proceed 
with all remedies allowed by law. This five day opportunity to 
cure shall apply only to the first violation of any kind at any 
Defendant establishment. 

IT IS FURTHER ORDERED that each operator-Defendant shall 
participate in the education of its patrons toward the prevention 

of high risk sexual activity including but not limited to that 

r 
suggested by the San Francisco AIDS Foundation. 



-5- 



246 



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5 AGNOST 

TOUNCY 
t CITY MALL 
'SCO IOJ 



This preliminary injunction shall be dissolved forthwith or 
upon notice by either party should the Director of Public Health 
declare the AIDS epidemic to be terminated. 

A copy of this order, including the attached Exhibit A, 
shall be posted in each room and hallway of the Defendants' 
establishments to which patrons are admitted. 

DATED: December^, 1984 



5448D 





ON. ROY L. WONDER 
of the Superior Court 



-6- 



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ORGE AGNOST 

::TV A7-1CNCY 
M J0 CITY P.AUU 
.-C SCO 1410 
lie J3'3 



247 



Exhibit A 
HIGH RISK SEXUAL ACTIVITY 

INTERIM DEFINITION 

For the purposes of this preliminary injunction, "high ris 
sexual activity" shall mean: 

(a) The placing of the penis of one male on or into the 
anus or mouth of another male; 

(b) The placing of the mouth of one male on the anus or 
penis of another male; 

(c) The contact of the feces or urine of one male with any 
part of the body of another male; or, 

(d) The entry of any part of the body of one male into the 
anus of another. 



-7- 



248 



I 

t 



December 21, 1984 



Hon. Roy L. Wonder 

Judge, Superior Court 

Department 8 

481 City Hall 

San Francisco, CA 94102 

Subject: People v. Owen, et al. 

(Superior Court No. 830-321) 

Dear Judge Wonder: 

I have reviewed the language of the Plaintiffs' proposed 
Modified Preliminary Injunction, and in particular the definition 
of "high risk sexual activity" contained in the Plaintiffs' 
Exhibit A. I have adopted and do endorse the language of that 
interim definition until such time as I have had an opportunity 
to confer with the San Francisco AIDS Foundation next month 
regarding this determination. I respectfully urge this Court to 
do the same. 



Very truly yours, 




MERVYN F. SILVERMAN 
Director of Public Health 



cc: All Counsel 



City and County of San Francisco Department of Public Health 



249 
1 ( 



PRESS STATIST? 

OF 

DR. MERVYN F. SILVERMAN 
October 9, 1984 



Today I have ordered the closure of 14 commercial establishments which promote 
and profit from the spread of AIDS - a sexually transmitted fatal disease. 
These businesses have been inspected on a number of occasions, and demonstrate 
a blatant disregard for the health of their patrons and of the community. 



We now have solid evidence that AIDS is a sexually-transmitted viral disease - 
often spread by people who are unaware that they are carrying the virus. 
Antibodies to this virus have been found in at least 40 - 50? of the gay male 
population studied in San "Francisco. We know that the more sexual activity 
involving exchange of body fluids, the greater the risk of contracting AIDS. 



From the beginning of this epidemic, we established a prevention program which 
placed major emphasis on education designed to inform the gay community about 
the nature of this disease and how it can be prevented. This became part of an 
overall approach by San Francisco that is serving as the model AIDS program for 
the rest of the country. Today's action is one part of this comprehensive 
program. 

Central Office 101 Grove Street San Francisco. CA 94102 



250 



The places that I have ordered closed today have continued in the face of this 
epidemic to provide an environment that encourages and facilitates the multiple 
unsafe sexual contacts, which are an important factor in the spread of this 
deadly disease. 



When activities are proven to be dangerous to the public and continue to take 
place in commercial settings, the Health Department has a duty to intercede and 
halt the operation of such businesses. 



Ma>e no mistake about it. These 14 establishments are not fostering gay 
liberation. They are fostering disease and death. 




City and County of San Francisco Department of Public Health 

251 



ORDER OF DIRECTOR OF PUBLIC HEALTH 
TO ABATE A PUBLIC NUISANCE 



TO: 
SUBJECT: 

ASSESSORS BLOCK: LOT: 

WHEREAS the Director of Public Health has determined that the 
incidence of Acquired Immune Deficiency Syndrome (AIDS) in San Francisco 
has reached epidemic proportions with the highest per capita incidence 
anywhere in the United States; and 

WHEREAS AIDS is a fatal disease with no known cure; and 

WHEREAS the Director of Public Health has determined that the 
operation of the above designated business contributed to the spread 
of the virus that causes AIDS; 

ACCORDINGLY, the Director of Public Health has determined that the 
continued operation of the above designated business constitutes a hazard 
and menace to the public health; 

THEN by virtue of the power yeilded in him by the law of the State 
of California, the Charter of the City and County of San Francisco, 
and the Ordinance of the City and County of San Francisco, 

THE DIRECTOR OF PUBLIC HEALTH FOR THE CITY AND COUNTY OF SAN FHANCISC( 
HEREBY ORDERS THE ABOVE DESIGNATED BUSINESS TO CLOSE NO LATER THAN 
12:00 O'CLOCK NOON, OCTOBER 9, 1984. 



"DATE ' MERVYN F. SILVERXAN, M.D., M.P.H. 

Director of Health 
City and County of San Francisco 



Central Office 101 Grove Street San Francisco, CA 94102 



252 



2166 Market Street 

San Francisco, CA., 94114 

ANIMALS 

161 6th Street 

San Francisco, CA. 94103 

BOOT CAMP 

1010 Bryant Street 
San "Francisco, CA 

CLUB BATHS OF SAN FRANCISCO 
201 8th Street 
San Francisco, CA. 

CLUB SAN FRANCISCO 

3^ Ritch Street 

San Francisco, CA. 94107 

DISCOUNT BOOKS 

114 Eddy Street 
San Francisco, CA. 

FOLSOM GULCH BOOKS 

947 Folsom Street 

San Francisco, CA. 941 0" 7 

JACK'S TURKISH BA"H 

1143 Post Street 
San Francisco, CA. 

JA3UAR AD T 1LT BOOK STOKE 
4056 18th Street 
San Francisco, CA 

SAN FRANCISCO HEAL^ CLUB 
229 Ellis Street 
San Francisco, CA 

SAVASE THEATRE 

220 Jones Street 
San Francisco, CA. 



HE SLO 

9 7 9 Folsom 

San Francisco, CA 



TEA ROC? 1 ' T 

145 Eddy Street 
San Francisco, CA. 

21st STREET BATHS 

3244 21st Street 

San Francisco, CA. 9^110 




BRIEFING 1>$ER 



. . . 

San Francisco's Action Against the Bathhouses 
and Sex Establishments 

Current Status: _ of the _ _ establishments remain open. 

Health Department inspectors monitor the remaining establishments for compliance 
with the court order that defines permissible activities. 

Within the next few months, the San Francisco City Attorney will go to court to 

request closure of approximately establishments that have been found to be 

operating in violation of the court order. 

History of San Francisco's Action 

Before Action (April to September 1984 

- Community Concern: The issue is debated among me in hers of the gay 
community and health professionals. In general, gay leaders .ire not willing to 
state publicly that they favor closure of the bathhouses despite v.hat they say " 
private. Many health professionals favor closure of the bathhouses. 

- Legal Preparation: The San Francisco City Attorney studies the issue in order to 
recommend what actions are available to the Director of Health, under State and 
local Health Codes. The City Attorney informs the Director that he can take 
the following actions: 

Close or quarantine the public bathhouses that are 
licensed and regulated under the City's Bathhouse 
Ordinance. This measure excludes private sex clubs 
that are not regulated under the ordinance and are 
often less sanitary than the public bathhouses. 

-Regulate the bathhouses and sex establishments -- both 
public and private -- to eliminate behavior that may 
lead to the spread of AIDS. 

-Take no legal action but continue to regulate 
informally and provide educational materials. 

The attorneys also consider: 

Transfer of responsibility for reg u 1 a t i ng ba thhouses 
(but not private sex establishments) from the Police 
Department to the Health Depariment in order to 
facilitate Health npnnrrrwnr regulation of these 
establishments. This proposal was rejected by the 
Board of Supervisors, San Francisco's legislative body. 
-In preparation, data are compil ed to jus t ify Heal th 
Department action. Health Department professionals 
begin to amass medical and scientific documentation to 
support the contention that the bathhouses and sex 
establishments are conducive to the spread of AIDS. 
Undercover inspectors visit the establishments to 
verify that activity likely to spread AIDS is taking 
place in each specific establishment. 

- Possibility of ballot issue furthers concern for action: During the summer, a gay 
activist (Larry Littlejohn) began to circulate an initiative petition for the 
November 1984 ballot that would call for closure of the gay bathhouses and sex 
establishments. This caused great concern among gay people and others 
concerns with the implications of holding a "gay referendum". After the City 
began to take action, Littlejohn withdrew the petition. 

- Closure of some establishments: Throughout this period, several establishments 



Page Two 254 

Action Against Bathhouses and Sex Establishments 

- City takes action: On October 9, 1984, the San Francisco Health Director 
announces his intention to take action against 14 bathhouses and sex 
establishments. The establishments immediately asked for a preliminary 
injunction against the Health Department's action. 

- Court amends action: On November 28, 1984 Judge Roy Wonder of the Superior 
Court issues his decision regarding the request for a preliminary injunction. 
Facilities can remain open only under these conditions: 

(1) no private rooms can be rented unless they are licensed to be 
operated as hotel rooms; 

(2) employees of the establishment shall be assigned to observe the 
activity on the premises the number of monitors needed is 
specified in the court order. They shall survey the entire premises 
every ten minutes and expel all patrons observed in high risk sexual 
activity as defined by the Health Department. Owners must report 
to the Health Department on the number of people expelled. 

(3) all doors to individual cubicles or booths must be removed. 

(4) owners shall educate patrons on what constitutes high risk sexual 
activity. 

(5) if violations of the court order are found by the Health Department, 
the owner shall be given 5 days from written notice to cure the 
violation. After that, the Health Department can close the facility. 

Results of Court Order to date: 

- Need for continual monitoring: the Court order requires continual monitoring by 
Health Department officials. This is difficult (inspectors should be undercover 
to be most effective). 

- Need to continue to gather evidence: Since the Court order, thn City began to 
compile evidence against those establishments violating the order; several more 
establishments closed due to lack of business. 

Summary 

San Francisco brought the action against several types of establishments where 
unsafe sexual activities take place: licensed bathhouses, backs of certain bookstores, 
certain movie theaters, private clubs. 

In court, the City demonstrated the following: 

- Scientific/medical evidence links certain sexual practices to AIDS; 

- There is evidence that these sexual practices are taking place in each of the sex 
gay bathhouses and sex establishments. On a continued and repeated basis that 
constitutes a grave danger to the public health. 

Health experts considered: 

- what action is most likely to affect people who might contract AIDS? 

- what action is most likely to minimize public hysteria about AIDS? 

Elements of Case Against the Bathhouses and Sex Establishments 

Required evidence that certain sexual practices are conducive to the 

spread of AIDS. 

Required evidence that these practices occur and are encouraged in these 

facilities. 

Required demonstration that the facilities were inspected on several 

occasions. 

Involved argument that government cannot condone such activities in 

commercial establishments that it licenses or which do business in the City. 

Required evidence that owners of the facilities knowingly allowed these 

unsafe and dangerous activities to take place. 

MK:ia 
9129R 



255 

UNIVERSITY OF CALIFORNIA. SAN FRANCISCO 



BERKELEY DAVIS IRVINE LOb ANGELES RIVERSIDE SAN DIECO SAN FRANCISCO \K 



AIDS Behavioral Research Project 

HOSPITALS AND CLINICS _ A 405 




SANTA BARBARA SANTA CRUZ 



SAN FRANCISCO, CALIFORNIA 94143 

731-7468 



TO: Mervyn Silverman, M.D. 

FROM: Leon McKusick, M.S. 
Steve Morin, Ph.D. 

DATE: April 3, 1984 
SUBJECT: Bathhouses and Public Policy 



The issue of closing bathhouses in San Francisco has produced a debate which 
seems to us has lost track of data that could reasonably be used to make a 
public policy decision. Frequently discussions have moved from medical issues 
to political or rights issues without an examination of medical, behavioral and 
epidemiological data. The following are sone thoughts. 

Medical Issues 

The proper policy question to be directed to medical advisors is: What is the 
most probable means of AIDS transmission? The medical consensus regarding AIDS 
transmission appears to be leaning toward the following: (1) blood to blood, 
e.g. transfusion cases; (2) semen to blood, e.g. cluster studies of sexual 
contacts; and (3) viral agent, e.g. SAIDS retrovirus model. 

In that public policy decisions on bathhouses must be based on the medical issue 
of sexual transmission, a very high consensus that AIDS can be transmitted from 
semen to blood would be needed. Public policy decisions would follow directly 
from this medical consensus. 



Behavioral Issues 

If semen to blood transmission is widely accepted by the medical advisors, then 
certain target behaviors could be identified with prevention efforts directed 
toward lowering the incidence of AIDS transmission, e.g. frequency of anal 
intercourse, receptive without condom. The proper question to be directed to 
behavioral science advisors is: Does the environment at bathhouses promote an 
increased frequency of high risk sexual behaviors (semen to blood transmission)? 

McKusick, Horstman & Carfagni (1984) conducted a study comparing men recruited 
from bathhouses to those recruited from bars, couple networks, and newspaper 



256 



Mervyn Silver-man, M.D. Page 2 April 3, 1984 



Behavioral Issues (continued) 

advertisements for those who did not attend bars or baths. Some of the 
following findings are relevant to public policy determinations: 

Disease transmission; Men sampled from bathhouses were significantly more 
likely than other groups to have had hepatitis B. Those sampled from 
bathhouses and bars were more likely than the other two groups to have had 
either gonorrhea or syphilis in the last year. 

Number of sexual partners; Men sampled from the bathhouses demonstrated a 
higher frequency of sexual partners than the other groups. Sixty-one 
percent of the men sampled in the baths reported 5 or more sexual partners 
in the last month; 32% reported 10 or more partners. 

High risk activity: Men sampled from bathhouses and bars were more likely 
than the other two groups to demonstrate high risk sexual behaviors. 
Forty-four percent of the bathhouse respondents reported anal intercourse, 
receptive without condoms with a new or secondary partner in the last 
month; 11% reported this behavior with 5 or more partners in the last 
month. 



Have Educational Efforts Been Successful? 

One argument that is frequently used by those opposing bathhouse closure is 
that gay bathhouses offer an opportunity to prevent the spread of AIDS through 
public education. However, the data collected on men sampled from bathhouses 
indicates a very high level of awareness regarding AIDS transmission. In this 
sample there was a 92% agreement with the statement that "AIDS is transmitted 
through body fluids." There was a 95% agreement with the statement "reducing 
the number of sexual partners overall helps reduce AIDS risk." These data 
suggest that men attending bathhouses have a very high recognition of risk 
reduction guidelines even though there behaviors do not conform to these 
recommendations. 



Would ClosinR or Altering the Baths Make a Difference? 

There appears to be strong belief (possibly a myth) on the part of many people 
that closing the baths would not change high risk sexual behaviors. This 
argument to some extent ignores the issue that many behaviors are situation 
specific and that people behave in different ways in different environments. 
High risk and high frequency sexual behaviors are directly related to 
environmental factors which support such behaviors. 



257 



Mervyn Silver-man, M.D. Page 3 April 3, 1984 



The American Association of Physicians for Human Rights (AAPHR) has released a 

statement on baths indicating "There is no evidence, at this time, that closing 

bathhouses would reduce the risk or incidence of AIDS." It is unclear whether 
the behavioral data above have been considered. 

Further, the AAPHR statement indicates "attempts at legislating sexual behavior 
have only changed locations of that behavior, not curtailed it." Although this 
statement may have validity regarding statutes, it is not relevant to the 
current issue for determination. 

Going back to the McKusick, et.* al. data, respondents of who do attend 
bathhouses (n=281) were asked if there were no bathhouses how their sexual 
behavior might be expected to change. They responded as follows: 

Would probably have the same kind of sex somewhere else 47% 

Would stop having the sex he now has in bathhouses 7% 

Would reduce the kind of activity he now has in a 
bathhouse but would still have some of this 

behavior elsewhere 28% 

Other changes 19% 

Self-report data on those attending bathhouses thus indicate that 53% would 
make significant changes if there were no bathhouses. 

Given the high probability that the number of behaviors such as multiple 
partners is easier in bathhouses and the opportunities as well as social skills 
necessary to engage in the same type of activities elsewhere may not be a part 
of the person's current social skills, the 45% who would not predict changes in 
their sexual behavior may be overestimating other options. To a large extent 
the policy issue of closing/altering bathhouses depends upon whether or not 
frequency of sexual partners and high risk activities are situation specific. 
The above data would suggest that they are. 

Conclusion 

This memo was prepared in part to refute the notion that there are no data 
indicating that the closing of the baths would reduce the incidence of AIDS. 
The above medical, behavioral and epidemiological data can be interpreted to 
suggest that closing or altering bathhouses could have a major impact on 
reducing high risk sexual behaviors and therefore the incidence of AIDS 
transmission. High risk and high frequency sexual behaviors appear to be 
situation specific. Current bathhouse environments appear to promote high 
volume and high risk behaviors. 

Most public policy decisions are made with far less data than are available on 
this issue. Although these data do no dictate one particular decision over 
another, they are are brought to your attention to help focus the public policy 
debate. 



/JTU' -A- ; 



K. 



OFFICE OH THE MAYOR 



August 9, 1984 




258 



DIANNE FEINSTEIN 



Honorable Willie Kennedy, Chair and Members 

Public Protection Committee 

Board of Supervisors 

City Hall 

San Francisco, California 94102 

Dear Chair and Members: 

If ever a piece of legislation cried out for adoption, it is the 
measure before you today regarding regulation of bathhouses (your 
calendar item 84). This measure would simply transfer the 
bathhouse ordinance from the Police Code to the Health Code. This 
would recognize the current enforcement situation, and give the 
Health Department jurisdiction over what is essentially a public 
health matter . 

- The bathhouse ordinance is directed towards health, rather 



than police concerns. 
protect public health 



The bathhouses 
concerns . 



are licensed in order to 



- Current enforcement efforts are carried out by health 
inspectors, rather than police officers. Even though the 
ordinance is now in the Police Code, enforcement is carried 
out by Health inspectors. The inspectors visit the bathhouses 
in order to ensure that they are complying with the sanitation 
and public health aspects of the ordinance. 

- The bathhouses are centrally involved in the major health 
issue facing our City: AIDS. As you know, the AIDS crisis is 
an extremely serious one: 

- To date there have been 642 cases of AIDS in San 
Francisco, with 261 deaths; an almost 41% death rate. 

- In the month of July, there were 54 new cases and 21 
deaths nearly 2 new cases a day. 

- In the first three days of August, there were 8 new cases 
and 4 deaths nearly three new cases each day. 

- A recent study in the City Clinic showed that over 50% 
and perhaps as much as 70% of gay males have been 
exposed to the AIDS virus . 

- The incubation period for the AIDS virus may be as much 
as five years . 



/ 



259 

Supervisor Willie Kennedy 
Page Two 



The regulation of bathhouses should be decided by doctors and 
health professionals on the basis of current epidemiological 
evidence and not by police untrained in health care. To leave the 
matter of disease control to police merely politicizes the issue 
by making police the scapegoats for those who want to obfuscate 
and procrastinate about the bathhouses. I urge your approval of 
this crucial legislation. 



I / , ., ^ 

b i Xnne ' l Fei us t el rf ' 
M^yor 



/DF/rnk 

' 5215R 



I. , 



IITY AD COUNTY OF SAN FRANCISCO 



06 City Hall 

00 Van Ness Avenue 

an Francisco, California 

415) 551-4123 



l^rrJ 



260 



94102 



/' OFFICE OF THE CITY ATTORNEY 

GEORGE AGNOST CITY ATTORNEY 

Philip S. Ware 
Chief Trial Deputy 



MEMORANDUM 

September 27, 1984 

PRIVILEGED AND CONFIDENTIAL 

TO: Mervyn Silverman, M.D., M.P.H. 

FROM: Philip S. Ward, Chief Trial Deputy \~'^ 
Daniel E. Collins, Deputy City Attorney 

SUBJECT: Closure of Bath Houses and Sex Clubs 



This is in response to your recent letter 

requesting advice as to what steps you may take in order to 
close any bath houses and sex clubs which are contributing to 
the spread of Acquired Immune Deficiency Syndrome (AIDS). 

In order that you are fully advised, we will cover 
the following topics in this memorandum: (1) the medical 
problem confronting you; (2) bath houses, sex clubs and AIDS; 
and (3) your authority as Director of Health under Section 
3110 of the Health and Safety Code to protect the public 
health by closing establishments promoting or facilitating 
the spread of disease. 

In sum, we will briefly describe the public health 
problem confronting you, suggest a means for determining 
which establishments are promoting or facilitating the spread 
of disease and outline a procedure for effecting closure of 
these establishments in the appropriate case. 



THE MEDICAL PROBLEM 



San Francisco has the highest per capita rate, 



and 



the second largest number of cases of AIDS, of any city in 
the nation. The best available medical evidence clearly 
indicates that AIDS is a highly communicable sexually 
transmitted disease occurring primarily in homosexual men. 
There have been 6122 cases reported nationally vitn 2300 
deaths to date. In San Francisco we have r.ad approximately 
700 AIDS cases diagnosed End 3CO deaths. Last ~cr.tr. ilcr.e 
there were 50 esses ciaqr.csed -ind 28 ie = tr.= 7. = 1 i.i::ie 



Jr ' ^'prvvn ^ Ivprman wi n M u u u:(jp y 

/I i liCLVyii Q A i V C^kiiUii / ilii/i/ iiiiiili t GMv 



ClO-iur^ 01" E * ' h Houses c- Sex Clubs 

261 



scientific sources indicate that antibodies to the AIDS virus 
have been found in the blood of 60-701 of sexually active gay 
males. AIDS is fatal. Although there is great hope that a 
vaccine and cure will be forthcoming over the next two to 
five years, the single most important goal at this time is to 
reduce the spread of AIDS by inducing behavioral changes in 
the highest risk group. 

Your panel of experts has recommended that -uitiple 
sexual contacts of an anonymous character between homosexual 
males be curtailed because the transmission of AIDS is likely 
to occur. The panel has advised you that the specific -exual 
activities that should be proscribed include multiple, 
anonymous sexual activities which involve the following: id) 
the placing of the copulatcry organ of one male on or in-.o 
the anus or mouth of another male, (b) the placing of the 
mouth of one male on me anus or copuiatory organ of anotr.er 
male, (c) the contact of the excrement of one male with any 
part of the body of another male, (d) the entry of any part 
of the body of one male into the anus of another. In the 
interest of brevity, this kind of specific sexual activity 
will be referred to herein as "high risk behavior". 

Homosexual males who frequent bath houses and sex 
clubs are the most likely persons to be engaged in the kind 
of behavior that can lead to AIDS. Studies show that the 
high risk behavior referred to above typically occurs at bath 
houses and sex clubs. In fact, these establishments 
frequently serve no other purpose but to afford the 
opportunity for gay males to engage in such high risk 
behavior . 

II 
BATH HOUSES, SEX CLUBS AND AIDS 

Though it may be obvious to you that many bath 
houses and sex clubs are locations where such high risk 
behavior in San Francisco takes place, it will be necessary 
to establish this as a matter of proof. Therefore, you 
should utilize city health inspectors, volunteer medical 
professionals and, conceivably, private investigators to 
irregularly surveii the suspect establishments on fiv= to ten 
separate occasions for purposes of determining if hi'h vi3k 
behavior is raking place. If frequent and blatant high cisk 
behavior is discovered, it will be easy to charge t.ie o'..,r.er 
and/or manager with actual or constructive knowledge of their 
patrons' conduct. Naturally the surveillances should OOV^L- a 
reasonable period of time to establish that the observed 
conduct IG net just transitory and isolated. 



r, Mervyn Silverman, O,, M.P.H, Page 3 September 27, 



262 



When you have gathered your evidence present it to 

this office and we will review it as to its legal sufficiency. 

We will advise you as to any additional evidence that may be 
needed. 

Ill 

YOUR AUTHORITY AS DIRECTOR OF HEALTH UNDER HEALTH 
AND SAFETY CODE SECTION 3110 

As Director of Health you are empowered to "take 
such measures as may be necessary to prevent the spread of 
[communicable] disease or occurrence of additional cases." 
(Health and Safety Code Section 3110). Section 3110 empowers 
you to take reasonable steps to protect the public health 
including the promulgation, of guidelines setting forth 
prohibited conduct, issuance of an "order to show cause" re 
closure and conducting hearings to determine whether specific 
practices are encouraging the spread of a disease Like AIDS. 

A. Notice Re High Risk Behavior 

You should send copies of the attached notice to V- 
all bath houses, sex clubs, and other establishments that you 
believe facilitate the proscribed multiple, anonymous sexual 
activity. Send the notice registered mail, return receipt 
requested. Enclose a cover letter advising the establishment 
that you have reason to believe that its operation promotes 
or facilitates indiscriminate, anonymous multiple sexual 
contacts that can lead to the spread of AIDS. Since your 
ultimate sanction of a closure order could also affect the 
property owner, you should send the notice to the business 
owner, the business operator, and the property owner of the 
building in which the business is located. A proposed form 
of notice is attached. You may order a lot book guarantee 
through Founders Title, 551 Polk Street, (ph. no. 864-3322) 
to ascertain the names of property owners. 

B . The Hearing Process 

After your investigators have gathered sufficient 
evidence for you to conclude that some establishments are 
being operated in a particularly egregious fashion in view of 
the notice, you should issue an crder to show cause re 
closure pursuant to Health and Safety Code Section 3110. 
That document would advise the business owner, the business 
ocerator and the owner of the building that you have reason 
to believe that the establishment is being operated in 
violation of the notice. The document would also acvise that 
the cirticular business is promoting the spread uf or tr.e 
occurrence of ndciticnal -.:ases of AITS. Finally, tne order 
would state tr.=t tr.e respondents must oe 



: ^, -v i^ 



r/Kervyn Silveraan, M,D,, H.P.H, Page 4 September 11, 198- 

: Closure of Bath H c u i * s & Stx Clubs 

263 



prepared on a specific date and rime to show cause in a 
Director's hearing why their business should net be closed. 
You will advise the business what sanction you are considering 
imposing and require the owners/operators to ccme forward and 
show cause why you should not impose that sanction. This 
office will of course assist you in the preparation of the 
order to show cause and any ether ancillary forms. 

You, as Director of Health, would conduct the 
hearing on the show cause order. Evidence would be received 
as to: (1) the medical issues (i.e. clinical course of the , 
disease, epidemiology, risk factors, aetiology and 
transmission, control, etc.), (2) the specific testimony 
concerning the high risk behavior at the establishment ( s ), 
(3) the connection between that specific conduct and the 
spread of AIDS, and (4) the evidence proving that the 
business failed to comply with the notice. A court reporter 
would be present to transcribe the proceedings, swear in 
witnesses and mark documentary evidence. 

If the evidence is sufficient and warrants it, you 
would order the bath house or sex club closed on a temporary 
or permanent basis. If the order is not obeyed, the City 
Attorney will go to court to enforce your order in the 
appropriate fashion. 

C. Red Light Abatement 

As an alternative to the order to show cause and 
hearing procedure set forth above, or as a supplement thereto, 
you may consider requesting the District Attorney to proceed 
under the Red Light Abatement Law, California Penal Code 
Sections 11225, et seq. 

Section 11225 provides in pertinent part that every 
building or place used for the purpose of lewdness, 
assignation or prostitution is a nuisance which shall be 
enjoined, abated and prevented. Section 11226 provides that 
whenever there is reason to believe that a nuisance is kept, 
maintained or is in existence in any county, the District 
Attorney must maintain an action in equity to abate and 
prevent the nuisance and to perpetually enjoin the person 
conducting or maintaining it, and the owner, lessee or agent 
of the building in or upon which the nuisance exists, from 
directly or indirectly maintaining or permitting it. Lewdness 
is given a broad definition extending "to all immoral or 
degenerate sexual conduct, including public ma =curbat ion . " 
The court r-.ay issue a temporary writ of injur.ct icr. tc or event 
the cent ir.uar.cre of the nuisance upon a shcw.r.z :: prescribed 
ccncuct made cv -.iff icavit or "cy verified corr.r: i.^ i r ~. ~ 



F Silrprrcsn M T) M D T 4 Daflp S Cpn-^'opr 07 IQfij 

ii uii Ciiiiuiif iiiif,, i'i 1 1 i n i TCMw J OCL/LviiLuCt LI / uoi 



of e.it h Houses S. * t Clubs 264 



A red light abatement case must show that the 
nuisance complained of existed at the time the action was 
riled. Mo showing of specific intent is required and the 
action may be sustained even where the owner has no actual 
knowledge of the activities taking dace on the cremises. 
Circumstantial evidence may be relied upon to prove that a 
building is maintained for unlawful purposes and evidence of 
the general reputation of a place is admissible to prove r.he 
existence of the nuisance. The testimony cf a competent 
investigator who has observed any such illegal acts may also 
be received. 

The Red Light Abatement Act provides that an orcer 
of abatement must direct the removal from the premises ana 
sale of all furnishings and fixtures. The building itself 
may also be closed for all uses for a period not to exceed 
one year or, in the alternative, the court may impose money 
sanctions in an amount equal to the fair market rental value 
of the property for one year. Additionally, the court has 
the traditional equitable authority to fashion any other 
appropriate remedy. Violation of an injunction issued under 
the Red Light Abatement Act is punishable as a contempt of 
court. The taking of an appeal does not stay the enforcement 
of an order cf abatement under this Act. 

We remain available to you for further advice and 
assistance as you deem necessary. 



cc: Mayor Dianne Feinstein 

PSVv : : DEC: jr 

4002D 



265 



NOTICE 

(To be sent registered mail, return 

receipt requested, to business owners, business 

managers and property owners.) 

Be advised that if the following conduct is observed on 
your premises so as to give rise to the assumption that such 
conduct is permitted, allowed, or encouraged by you or by persons 
under your supervision and control, or is otherwise constituting 
a danger to the public health by promoting the spread of or 
occurrence of additional cases of Acquired Immune Deficiency 
Syndrome (AIDS), this Department will take immediate action to 
suspend or terminate the operation of your business: 



(a) The placing of the copulatory organ of one 
male on or into the anus or mouth of another 
male; 

(b) The placing of the mouth of one male on the 
anus or copulatory organ of another male; 

(c) The contact of the excrement of one male with 
any part of the body of another male; 

(d) The entry of any part of the body of one male 
into the anus of another . 



NERVYN F . SI LVERMAN , M . D . , M . F . H 
Director of Health 

4014D 




266 



PRESS STATEMENT 

OF 

CIVIL RIGHTS AND LESBIAN AND 
GAY COMMUNITY ORGANIZATIONS 
10/10/84 



In this medical crisis, our primary goal is to stop the transmission 
of AIDS and to save lives in San Francisco. The closure of certain 
gay businesses and other actions by the health director are certain to 
have a contrary result and also to adversely affect civil rights here 
and elsewhere. 

Closing the baths is wrong and dangerous. Medical decisions reqajcd,j.n 
public healthissues must be based on ^.oJJLjL > sJlleji^ifjL T C__ey i d jen c e . / 
^cientific ~cJat"a7~:Lncluding the most "recent data from 'the 'Centers 
[Disease Control in Atlanta (CDC) , show that there is no correlation 
Ibetween the risk of acquiring the disease and bathhouses. These 
(_wer_e_jconf irmedas late as .y e s t e r day ^y i th__rjes&a Jchexsu.ai: J _-CDC_ J ^J"Tht 
Francisco AIDS Foundation research confirms, it is what one does which 
creates risk. The correlation to a particular site is non-existent. 

We deplore the politicization of the medical issues and view the focus 
on one small scapegoated aroup as unjustified and wrong. The present 
action sends out the wrong message that government has finally done 
something effective and conclusive. It has not. The government must 
focus on finding continued funding for research and education. 

The accurate information shows that education of the entire community 
is the most effective means of ensuring the public health of the lesbian 
and gay community. The bathhouses have served as one of the major 
conduits of that information, and the subsequent historically unparal 
leled reduction in VD rates attests to the success of this apprjpach. 
The he aTfh d-ir ecto'r" has had all of "this "information-, including the"" 1 
CDC study, for almost two months. 

The actions of Dr. Silverman also sends the wrong message to the gay 
and lesbian community. Staying away from bathhouses does not lower the 
risk of encountering the disease; the efforts to educate the whole 
community as to what does effect the risk factor must continue. 

The action sends a dangerous message to the public at large that gay 
males and lesbians a group that has historically been the object 
of society's fears and hatred is worthy of censure by government. 
The rationale for discrimination or violence that can be drawn from 
this action is especially troubling. 

Use of the power of the health director without supporting data, under 



267 

PRESS STATEMENT OF CIVIL RIGHTS AND LESBIAN AND GAY COMMUNITY ORGANIZATI 
Pane Two 10/10/84 



great political pressure, in contradiction to existing medical informa 
tion, and without circumspect consideration of all consequences, 
creates a dangerous precedent. 

We remain committed to a '5t>int effort of working for the saving .of 
lives and for the integrity of government which has been compromised 
here. 



Jay M. Kohorn, 

American Association for Personal Privacy 

Dennis McShane, 

Bay Area Physicians for Human Rights 

Roberta Achtenberg, 

Bay Area Lawyers for Individual Freedom 

Doug Warner, 

American Civil Liberties Association of Northern California 

Fred Rosenberg, 

Golden Gate Business Association 

Tom Steel, 

Northern California Bathhouse Association 

Paul Castro, 
People With AIDS 






268 

MERVYN FRANK SHVERMAN, M.D., M.P.H. 

Appendix F 

Professional: Residence: 

San Francisco Health Department 119 Frederick Street 

101 Grove Street San Francisco, CA. 94117 

San Francisco, CA. 94102 (415) 861-5540 
(415) 558-2466 

BACKGROUND SUMMARY: 

Over 1 7 years of experience in Health Care Administration with particular 
emphasis in Community Health Services and Organizational Management on 
local, state, national, and international levels. 

Directorships have included two local Public Health Departments, a state 
wide Planned Parenthood Program, the F.D.A. Office of Consumer Affairs, and 
a Peace Corps Regional Medical Program. 

EDUCATION: B.S. Washington and Lee University, 1960 
M.D. Tulane University, 1964 
M.P.H. Harvard University, 1969 

Stanford University, 1981 (Executive Program in 
Organizational Management) 

SPECIALTY CERTIFICATION: Diplomate, American Board of Preventive Medicine 

(General Preventive Medicine) 

PROFESSIONAL EXPERIENCE: 

DEPARTMENT OF HEALTH, San Francisco, California May, 1977 - present 

Chief Executive Officer for public health agency of 5,000 employees serving 
650,000 residents through a $270,000,000 program providing the full 
spectrum of health care services. 

WICHTTA-5EDGWICK COUNTY DEPARTMENT OF COMMUNITY HEALTH, Vichita. Kansas 
Director of Health Sept., 172 - May, 19"' 

Directed Department serving 385,000 residents through programs of environ 
mental health and community health services, and provided clinical 
supervision and direct patient care in tuberculosis, venereal disease, 
family planning and child health programs. 

PLANNED PARENTHOOD OF KANSAS May, 1976 - May, 1 P"" 7 

Medical Director 

Provided medical direction, clinical supervision and direct patient care 
for family planning services. 



269 

Mervyn F. Silvennan ?age 2 

FOOD AND DRUG ADMINISTRATION, Washington, B.C. 

Special Assistant to the Commissioner June, 1Q69 - Sept., 1970 

Director of the Office of Consumer Affairs Sept., 1970 - Sept., 1972 

Provided assistance to the Commissioner on legislative and organizational 
matters and directed a nationwide program of consumer services. 

MODERN MEDICINE PUBLICATIONS, Minneapolis, Minnesota 

Contributing and Consulting Editor 1 9 7 - 1 975 

PEACE CORPS 

Regional Medical Director for Southeast Asia and 

the Pacific (Washington, D.C.) 1967-1968 

Peace Corps Physician (Thailand) 1965 - 1967 

Directed 25 Peace Corps physicians throughout the South Pacific and Southeast 
Asia. Provided direct health care for Peace Corps volunteers in Thailand. 

OTHER SIGNIFICANT POSITIONS 

KPIX TV 1979 - present 

"Resident Physician" for CBS-TV affiliate in San Francisco with regular 
TV appearances discussing health issues. 

Contributing Editor for Health! ine 1 9S3 - present 

Retirement Seminars 19 7 9 - present 

Provide lectures on Health and Retirement to the U.S. government, 
Wells Fargo, Bechtel, and other corporations. 

KMPX Radio 1979 - 1961 

Director, Producer and Host of Health Program airing weekly with 
interviews of health professionals. 

ACADEMIC AND OTHER APPOINTMENTS: 

Present; 

University of California School of Medicine - Associate Clinical Professor 
University of Hawaii - Associate Clinical Professor 

Tulane University School of Public Health- & Tropical Medicine - Adjunct 
Associate Professor 

PAST 

Advisory Health Council, State of California - Vice Chairperson 
National Center for Health Services Research (HHS) - Consultant 
University of California School of Public Health, Berkeley, 

California - Instructor 

St. Mary's College, Moraga, California - Instructor 
Wesley Medical Center, Wichita, Kansas - Teaching Staff 
Wichita State University Branch of the University School of Medicine - 

Clinical Associate 
Consumer Product Safety Commission -Member, Product Safety Advisory 

Council 
National Health Council, Member, Committee for Consumer Concerns 



270 



Mervyn F. Silverman 



Page 3 



PROFESSIONAL AND COMMUNITY SERVICE EXPERIENCE: 

Active Member, Board of Directors 

United States Conference of Local Health Officers - President Elect 
National Association of County Health Officials 
American Association of Public Health Physicians 
Health Officers Association of California 
California Conference of Local Health Officers 

American Heart Association, San Francisco Chapter, Board of Governors 
'Medical Advisor to Board of Directors, Golden Gate Chapter, San Francisco 

Region, American Red Cross 

Bay Area Chapter of March of Dimes Birth Defects Foundation 
Tenderloin Senior Outreach Program, Inc. 
San Francisco Regional Cancer Foundation, Board of Trustees 
United States - China Educational Institute 
Tulane Medical Alumni Association 

OTHER AFFILIATIONS: 

Present 

San Francisco Medical Society Delegate to California Medical 

Association (CMA) 
Chairman - Advisory Panel on "Preventive Medicine & Public Health (CMA) 

Past 

Coordinating Committee for Geriatrics Curriculum and Program, UCSF 

Delinquency Prevention Coordination Committee, San Francisco 

Advisory Board, Collaborative Health Program, San Francisco 

Professional Advisory Committee, Mental Health Association of San Francisco 

Advisory Committee, Bay Area Planned Parenthood 

Representative-at-large, California Public Health Association 

Member, Special Committee on the Future of Publicly Funded Health Services 

in California, State Department of Health Services 
Member, Drug Abuse Council, Wichita, Kansas 
Member, Advisory Board, Mid-American All Indian Center 
Member, Board of Directors, Child Abuse Foundation in Wichita, Inc. 
Member, Advisory Board, Black Nurses Association, Wichita, Kansas 



PAPERS AND PUBLICATIONS: 

Mervyn F. Silverman and Deborah B. Silverman, "Medical Ethics and Psycho- 
tropic Drugs," Maurice 1. Visscher, M.D. (ed.), Humanistic Perspectives 
in Medical Ethics , Prometheus Books, Buffalo, N.Y., 1972, pp. 223-217. 

Quarterly Articles for Healthline 

Monthly Article for San Francisco Medicine (Journal of the San Francisco 
Medical Society). 1979 - 1981 . 

Guest Editorial for Urban Health (The Journal of Health Care in the Cities), 
"The Self -Defeating Philosophy of Human Service Retrenchment," Sept., 1980. 



271 

Mervyn F. Silverman 

PROFESSIONAL ORGANIZATIONS: 

American College of Preventive Medicine 

San Francisco Medical Society 

California Medical Association (Chairman, Advisory Panel on Preventive 

Medicine); (Commission on Community Health Services). 
American Public Health Association 
American Medical Association 
California Academy of Preventive Medicine 

HONORS: 

Delta Omega Honorary Public Health Society 

Adjunct Scholar, Kansas Newman College 

Who's Who in American Universities and Colleges 

Who's Who in Government 

Who's Who in the Midwest 

Who's Who in the West 

Who's Who in California 

The Jacob C. Geiger Medal for the Best Thesis on a Public Health Problem, 

Tulane University 
B.S. Degree cum laude (Dean's List, Honor Roll) 

MEDICAL LICENSURE: California 



272 

INDEX--The AIDS Epidemic in San Francisco: The Medical Response, 1981- 

1984, Volume I 



Abbott Pharmaceutical Company, 

173 
Abrams, Donald I. 13, 30, 51, 62, 

65, 68, 97, 117, 134 
Agnost, George, 143-154, 150, 

152-153, 155, 156 
AIDS, passim 

beginnings, 115-117 

blood screening, 172 

city money for AIDS services, 

140-141 

complexity, 123-124 
early cases of, 10-13 
education, 118-122, 138-140, 

146-148, 160 

etiology, 15-17, 20-22, 93-94 
as a gay disease, 117-118 
government's role, 137-138, 

182-184 

impact on medicine, 173-177 
media, 181-182 
name, 117-118 
screening clinics, 135-137 
testing, 172-173 
turf battles, 116-117 
AIDS drugs 

accelerated approval of, 103- 

104 

AZT, 20, 66, 71, 104 
ddC, 104 
ddl, 104 

pentamidine, 12, 13 
AIDS opportunistic infections, 
17-20, 24, 30, 62-69, 74-75, 
99-100 

amebiasis, 7, 8, 12 
Burkitt's lymphoma, 18, 22, 

24, 64, 70, 75, 99, 100 
candidiasis, 18, 22, 73, 99 
cryptosporidiosis, 14, 19, 

70, 74, 99 
cytomegalovirus, 11, 14, 22, 

63, 75, 76, 93, 99, 100 
Epstein-Barr virus, 18, 22, 

76 
herpes zoster, 19, 22, 30, 

93, 99 



Kaposi's sarcoma, 10, 11, 13, 
14, 17, 18, 20, 22, 26, 
29-32, 34, 35, 47, 54, 
57, 62-65, 67, 70, 73, 
74, 82, 99, 116, 118, 
126 

non-Hodgkins lymphoma, 18 
Pneumocystis carinii 

pneumonia, 10-14, 17, 26, 
30, 35, 65, 66, 74, 79, 
100, 115, 118, 177 
shigella, 7, 8, 66 
Alice B. Toklas Memorial 

Democratic Club, 8, 62, 122, 
141 

Altman, David, 13, 30 
Altman, Drew, 179 
American Foundation for AIDS 

Research, 124, 125, 169, 175, 
183 
American Medical International, 

169 
American Public Health 

Association, 173 
Ammann, Arthur J., 26, 35-38, 40, 

43, 54, 59, 69, 102 
And the Band Played On, 126, 140, 

151, 153, 168 

Anderson, Stuart, 51, 71, 72 
Andrews, Richard, 47, 50, 134 
Auerbach, David, 29, 34, 35, 59 

Bacigalupi, Ed, 88 
bathhouse issue, 6, 7, 16, 17, 
49-51, 60, 72, 73, 78, 86-93, 
98, 110, 122, 126, 132, 135, 
137, 140, 143-169 
civil liberties versus public 

health, 160-162 
decision for closure, 156, 

163-165 

education, 146-148, 160 
and Feinstein, 143, 144, 150, 

151, 152, 156-158, 160, 

164, 168-169 
gay community resistance, 

146-149, 150-152, 153 



273 



press conference, March 30, 
1984, 150, 152-155 

press conference, April 9, 
1984, 149-150 

press conference, October 9, 
1984, 156 

regulation, 143-145 

reopening, 159-160 

Silvennan resigns, 165-169 
Bauer, Gary, 183 
Bay Area Physicians for Human 

Rights [BAPHR], 5, 47, 48, 

55, 83, 92, 114, 134 
Bay Area Reporter, 55, 149 
Benjamin, Robert, 55 
Bennett, William, 183 
Boas, Roger, 112-113, 151, 165- 

166, 168 

Bolan, Robert, 47, 50, 73 
Boucher, Louis "Bud", 66 
Bowen, Bob, 134 
Britt, Harry, 47, 53, 62, 89, 92, 

119-120, 144, 155, 158 
Burroughs Wellcome Pharmaceutical 

Company, 71 
Bush, George H. W. , 27 

Campbell, Bobbi, 13, 32, 50, 73 
census track study, 142 
Cities on a Hill, 164 
Community Advisory Committee on 

AIDS, 135 
Conant, Marcus, 13, 14, 29, 30, 

47, 51, 54, 57, 75, 116-117, 

134, 149, 150, 151, 153, 154, 

159 

Conte, John E., Jr., 13, 30, 69 
Corey, Hope, 58 
Curran, James, 16, 29, 41, 63, 

64, 103, 137, 144 
Curry, Francis, 4, 5 

Dague, Paul, 13, 30 

Darrow, William, 16, 29, 34, 35, 

59 
Democratic National Convention, 

San Francisco, 1984, 144, 

148, 158 

Deukmejian, George, 94 
Dritz, Selma, 115, 124, 126-127, 

134, 137, 163 



Dugas, Gaetan, 34, 35, 37, 59, 
85-88 

Echenberg, Dean, 91, 163 

Enlow, Roger, 65 

enteric disease, 5, 7, 17, 22, 

33, 66, 70 
Essex, Myron "Max", 23 

Fannin, Shirley, 35, 54 

Feinstein, Dianne, 50, 53, 90, 
92, 112, 120, 131, 132, 136, 
141, 143, 144, 150, 151, 152, 
160, 164, 166, 168-169, 181 

Foege, William, 63 

Food and Drug Administration 
[FDA], 40 

Francis, Donald, 4, 29, 43, 44, 
60, 96 

Friedman-Kien, Alvin, 21, 22, 
65-67 

Gallo, Robert, 22, 23, 42, 76, 

97, 105, 116 
Gardner, Murray, 23 
gay community, San Francisco 

and bathhouse issue, 146-149, 
150-152 

diversity, 121-123, 165 

links with public health 
department, 113-114 

political power, 131-132, 

151, 165 

Geary, James, 31 
Glaser, Eva, 75 
Goedert, James, 40, 66 
Goldberg, Whoopie, 126 
Goode, Erica, 64 
Gorman, Mike, 142 
Gottlieb, Michael, 10, 17, 35, 64 
Groundwater, James, 10, 13, 32, 

73 

Guinan, Mary, 29 
Guzman, Simon, 14, 19, 73 

Harvard University, 107 

Harvey Milk Gay Democratic Club, 

62, 122 

Heckler, Margaret, 172-173 
hepatitis A virus, 7, 8, 13, 42, 

66, 81 






274 



hepatitis B virus, 8, 13, 38, 42, 
44, A5, 51, 6A, 66, 67, 69, 
76, 85, 95 

Home, Ken, 10, 32 

Hudson, Rock, 26, 32 

human immunodeficiency virus 
[HIV], 13, 17, 19, 20, 28, 
38, 42, A3, A5, 57, 86, 95, 
97, 100 

human T-cell leukemia virus 
[HTLV], 22-2A 

Hutt, Peter Barton, 176 

Irwin Memorial Blood Bank, 38, 
44, 76, 83 

Jacobs, John, 55 

Jaffe, Harold, 16, 29, 39, Al 

Jelinek, Paul, 179 

Kaiser Permanente, 111 
Kansas state 

Planned Parenthood, 107 

Wichita director of health, 

107, 109-110 
Kaposi's Sarcoma Research and 

Education Foundation (now the 

San Francisco AIDS 

Foundation), 118, 121, 138, 

139 

Kellner, Aaron, AO 
Koch, Robert, AA, 8A, 103 
Kopp, Quentin, 166 

Laguna Honda Hospital, 110, 11A 
Lancet, 1A2 
Lang, Michael, 51, 63 
Laubenstein, Linda, 10, 3A, 63, 

67 

Lee, Phil, 1A3, 1AA, 179, 180 
Levy, Jay, 13, 23, 29, 30, 51, 96 
Littlejohn, Larry, 90, 91, 150, 

159 

Lorch, Paul, 1A9 
Los Angeles Department of Public 

Health, 139 

Lozada, Francine, 18, 30 
lymphadenopathy , 20 

McKusick, Leon, 30, 146-147, 158- 
159 



Marmor, Michael, 63 

Mass, Martin, 67 

Meyers, Beverly, 111 

Migden, Carole, 154 

Milk, Harvey, 8, 47, 62 

Molyneaux, Glenn, 33, 47 

Mondale, Walter, 152 

Montagnier, Luc, 42, 76, 97, 105, 

116 
Morbidity and Mortality Weekly 

Report, 115 
Morrison, Cliff, 129 
Moscone, George, 47 
Moss, Andrew, 70, 76, 105, 142, 

143 

National Institutes of Health 

[NIH], 16, 40, 76, 77, 96, 97 
Centers for Disease Control 
and Prevention [CDC], 12, 
15-17, 24, 26, 28, 29, 33, 
34, 36, 39-42, 54, 59, 60, 
63, 65, 68-70, 75-77, 81, 
83, 84, 94, 95, 96, 99, 
100, 103 

National Cancer Institute 
[NCI], 16, 28, 40, 77 
National Institute of Allergy 
and Infectious Diseases 
[NIAID], 16, 28, 77, 96 
Nelder, Wendy, 121, 155 
Norman, Pat, 113, 124-125, 142 

O'Malley, Paul, 69, 76 

Pasteur Institute, 76, 97, 103 

Pauling, Linus, 72 

Perkins, Herbert, 37, 38, 40, 44, 

83 

Perlman, David, 30, 47, 55, 80 
Petit, Charles, 30, 55 
"poppers" (amyl nitrites), 15-16, 

21, 36, 94 
Prince, Al, 67 

Quayle, J. Danforth, 27 

Ralph K. Davies Medical Center, 

56 
Reagan, Ronald W. , 27, 94, 182- 

18A 



275 



Rendon, Carlos, 94 

Robert Wood Johnson AIDS Health 

Services Program, 130, 169, 

174, 178, 179-181 
Roff, Hadley, 152 
Roselli, Sal, 141 
Rubenstein, Arye, 65 

Safai, Bijan, 68 

Salvitierri, Dr. Oscar, 12, 65, 

74 

Sande, Merle, 46, 51, 52, 174 
San Francisco Advocate, 55 
San Francisco AIDS Foundation 

(formerly the Kaposi's Sarcoma 
Research and Education 
Foundation), 31-32, 54, 57, 
82, 118, 121, 138, 139, 140 
San Francisco Board of 

Supervisors, 6, 47, 48, 52, 
53 

San Francisco Chronicle, 26, 30, 
47, 55, 89, 90, 92, 120-121, 
141, 181 
San Francisco County Community 

Consortium, 13, 97 
San Francisco Department of Public 
Health, passim 
AIDS Activity Office, 120, 

124-126 
and bathhouses, 49-51, 85-93, 

and passim 
Bureau of Communicable Disease 

Control, 126, 163 
community relations, 31-34, 

82 
Division of Communicable 

Diseases, 115 
educational efforts, 118-122, 

138-140, 146-148 
emergency aid stations, 111- 

112 
Health Director's Medical 

Advisory Committee on AIDS, 
133-134, 146, 155 
Lesbian and Gay Coordinating 

Committee, 125 
Medical Advisory Committee on 

AIDS, 46-53, 77, 83 
and other agencies, 53-55 
pre-AIDS, 4-9 



and the press, 26-27 

public outreach and education, 

72-73, 75-82 

San Francisco diversity, 109-110 
San Francisco Examiner, 26, 55, 

86, 92 
San Francisco General Hospital, 

13, 46, 51, 52, 58, 110, 111, 

112-113, 117, 126, 128, 134, 

135-136, 141, 165, 168, 177 

Kaposi's Sarcoma Study Group 
and Clinic, 29, 30, 47, 54 

Ward 5A (inpatient), 116, 
129-130 

Ward 5B, 46, 75, 102 

Ward 85 (outpatient), 127 
San Francisco Medical Society, 

33, 46, 47, 52, 67, 83, 110 
San Francisco model of AIDS care, 

129-130, 174, 177-181 
Schietinger, Helen, 29-31 
Sencer, David, 40, 63 
Sentinel San Francisco, 55 
Shanti Project, 31, 82, 121 
Shilts, Randy, 26, 55, 89, 90, 

92, 119-122, 140, 151, 153, 

168, 181 
Silverman, Mervyn, 4, 5, 18, 32, 

46-48, 50, 52, 78, 80, 81, 

86-93, and passim 

appointed San Francisco health 
director, 107 

consensus-building leadership 
style, 112, 119, 129, 131, 
153-154 

difficulty of bathhouse issue, 
167 

early career, 107-109 

education, 107 

interest in public health, 
108-109 

powers as health director, 

133, 162 

Smith, David, 82 
Sox, Ellis, 4, 5 
Spira, Thomas, 41-44, 65 
Stephens, Boyd, 56 
Stonewall Gay Democratic Club, 

62, 122 
Sullivan, Louis, 104 



276 



Tavern Guild, 8, 11, 62, 78 
Taylor, Elizabeth, 32 
Templeton, Alexander C., 64 
Thomas, Pauline, 63 
Tomlin, Lily, 126 
tuberculosis, 4, 5, 54, 68, 84, 

105 
Tulane Medical School, 107 

United States 

Consumer Affairs, Office of, . 

107 
Food and Drug Administration, 

107, 173, 175-176 
Health and Human Services, 
Department of, 172-173 
National Institutes of Health, 
174, 175 

Centers for Disease Control 
and Prevention, 136- 
137, 144, 183 

Peace Corps, 107, 108-109 
United States Conference of Local 

Health Officers, 164, 172 
United States Conference of 

Mayors, 132, 181 
University of California, San 

Francisco, 5, 12-14, 17, 29, 

30, 36, 38, 51, 54, 65, 69, 

74, 75, 83, 97 

Conant at, 117 

Institute for Health Policy 

Studies, 179 
Moffitt Hospital, 128 

KS Clinic, 128 
relations with health 

department, 111 
Task Force on AIDS, 117, 137 
van Gorder, Dana, 47 
veneral disease, 7, 54, 59, 77, 

105 

vitamin C, 71, 72 
Volberding, Paul, 13, 30, 51, 62, 
68, 91, 92, 116-117, 129, 134, 
153 

Washington and Lee University, 

107 

Werdegar, Dave, 180 
Whitraire, Kathy, 181 



Winkelstein, Warren, 24, 25, 51, 

58, 68, 84, 85 
Wofsy, Constance, 105, 117 
Wonder, Roy, 159-160 

Young, Frank, 173 

Ziegler, John, 18, 30, 64, 75, 83 



Sally Smith Hughes 



Graduated from the University of California, Berkeley, in 
1963 with an A.B. degree in zoology, and from the University 
of California, San Francisco, in 1966 with an M.A. degree in 
anatomy. After completing a dissertation on the history of 
the concept of the virus, she received a Ph.D. degree in the 
history of medicine from the Royal Postgraduate Medical 
School, University of London, in 1972. 

Postgraduate Research Histologist, the Cardiovascular 
Research Institute, University of California, San Francisco, 
1966-1969; medical historian conducting the NEH-supported 
History of Medical Physics Project for the History of 
Science and Technology Program, The Bancroft Library, 1978- 
1980. 

Presently Assistant Research Historian in the Department of 
History of Health Sciences, University of California, San 
Francisco, and an interviewer on medical and scientific 
topics for the Regional Oral History Office. The author of 
The Virus: A History of the Concept, she is currently 
interviewing in the fields of health maintenance 
organizations, virology, public health, ophthalmology, and 
molecular biology/biotechnology. 



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U.C.BERKELEY LIBRARIES 




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