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AIDS: Science and Reality BY MARY O’GRADY DRAGON WITHIN THE GATES: The Once and Future AIDS Epidemic By Stephen C. Joseph, M.D. 272 pages. New York: Carroll & Graf. $20.95 AS REAL AS IT GETS: The Life of a Hospital at the Center of the AIDS Epidemic By Carol Pogash 255 pages. New York: Birch Lane Press. $18.95. DRAGON WITHIN THE GATES begins with an intelligent, readable explanation of the origin and biology of the Human Immunodeficiency Virus, or HIV. The author, Dr. Stephen Joseph, a Health Commissioner for New York City from 1986 to 1990, is a public health doctor who writes about the AIDS epidemic in terms of sound classical epidemiology. Joseph advocates the confidential reporting of AIDS cases to public health authorities, as well as aggressive contact tracing and partner notification, still used by city and county health departments in cases of other communicable diseases. He says that HIV testing must become routine in all health care settings. Only by these means, he argues, can we begin to protect the uninfected and to get realistic data on the spread of the HIV epidemic. He provides a Jucid account of the history of the AIDS epidemic in New York City, as well as an ironclad explanation, in evolutionary terms, of why HIV is relatively difficult to transmit and highly unlikely to mutate into a virus communicable by casual contact. Joseph’s writing on the scientific aspects of HIV disease is altogether excellent, as well as accessible to the general reader, and much of what he says is incontestable. Unfortunately, the strategies of classical epidemiology break down in the face of an illness as stigmatized and politicized as AIDS. In a recent radio interview, Joseph said that the politics of fluoridation of public water supplies, and of mandatory childhood vaccination, resulted in dilemmas similar to those surrounding HIV testing and case reporting. In his book, he mentions tuberculosis and cancer as diseases considered shameful in 19th Austin writer Mary O’Grady is better known as The Observer’s “Bad Bills Girl.” century America. The stigma of tuberculosis and cancer are things of the past, and opposition to fluoridation and vaccination has largely disappeared. So Joseph infers that the hysteria surrounding HIV disease will likewise die down with the passing of time, and therefore he defends his traditional, authoritarian approach to the epidemic. He fails to consider that neither water fluoridation nor vaccination nor TB nor cancer had any connection to the explosive subjects of sex and drugs, and hence the controversies surrounding them were of a different order of magnitude. To his credit, Joseph’s many unpleasant public and private experiences with AIDS activists do not alter hiS approach to the problem, and in his arguments and his account of his experience of experiences as health commissioner he remains an unemotional scientist. At the same time, his fundamental detachment means that he has no grasp of the stigma that has surrounded AIDS from the beginning. But Stephen Joseph obviously lives in a scholarly, gentlemanly, and above all, financially stable world, where a diagnosis will not, cannot lead directly and immediately to rejection, ostracism, homelessness and solitary death. ‘ As Real As It Gets depicts a far different world: San Francisco General Hospital. \(The title comes from the slogan on T-shirts worn by San Francisco General emergency room 24-year-old nurse “Jane Doe” sticking herself in the finger with a patient’s used hypodermic needle. Jane Doe was infected by this accidental exposure to a stranger’s blood. Her story, complemented with the sad dramas that unfold as her family and friends learn her HIV status, and her long, hard fight to win compensation for her occupational exposure to the virus, is the thread that ties together a series of accounts of human experiences at the epicenter of the AIDS epidemic. In July of 981, Dr. Paul Volberding opened a tiny oncology clinic at San Francisco General. On his first day, he saw a wizened, dying 22-year-old with a rare cancer most common among elderly Mediterranean males: Kaposi’s sarcoma. He treated this man for his cancer, and the man, homeless and friendless, took to hanging around the clinic. Through this first patient the staff was introduced to the practice of self-taught social work. By the time of his death from an atypical pneumonia that autumn, the young man with the unlikely diagnosis had been followed by a string of fellow sufferers, all too young to bear the marks of Kaposi’s sarcoma. From Hong Kong, San Francisco General drew Dr. Hin-Wing Yeung. He wanted to test, on AIDS patients, the Chinese herbal medicine which was to become known as Compound Q. With only three known HIV-positive people in Hong Kong in 1986, he correctly assumed that San Francisco was a more likely location for a trial. At the General, researchers Michael McGrath and Gifford Leong became interested in the Hong Kong doctor’s vials of homemade white powder. Pogash explains the basic mechanics of the Compound Q trial that San Francisco General conducted for the Food and Drug Administration from the viewpoint of registered nurse Vince DeGenova, himself HIV-positive, who was responsible for recruiting patients for the experiments. She also writes of the rumors and hopes the drug inspired, until its years of trials yielded no good results. \(Before long, as word of the drug’s promise spread, and DeGenova’s own health deteriorated, he found himself inundated with pathetic letters, offers of bribes, and the odd foreigner arriving direct from the airport to his doorstep, all pleading for enrollunorthodox trial of Compound Q organized by the AIDS activists of Project Inform, who quickly became disgusted at the glacial pace of the FDA’ official investigation. The book describes the development of the world’s first hospital ward designated for AIDS patients: Unit 5A at San Francisco General. To segregate patients with a disease universally feared but not readily transmissible flew in the face of accepted nursing practice, but by 1983, the sorrowful anecdotes could no longer be ignored: the dying AIDS patient refused Last Rites by a self-righteous priest, the sick men lying in soaked bed linen, dirty meal trays lying on dirty floors, the placards screaming CONTAMINATED AREA on AIDS patients’ doors. \(San Francisco General was at that time one of a tiny handful of institutions with any experience at all dealing with HIV. Similar antediluvian standards of care continue in 1993 for HIV-infected patients unfortunate enough to land in facilities that have not made conscious efforts at staff education about the 5A was created specifically to provide humane care to those who had been denied it elsewhere in the hospital. Before it opened THE TEXAS OBSERVER 29