First Reports

When a puzzling new medical syndrome was first reported to be afflicting—and killing—young gay men in certain cities in the United States, there was no particular reason to expect that the cause might be a previously unknown virus. Nor did the deaths immediately take on any great medical significance. Michael Gottlieb, a young immunologist at the teaching hospital of the University of California at Los Angeles, began seeing such cases in late 1980 but found that he couldn't spark the interest of the New England Journal of Medicine , the most prestigious medical journal in the country, later to publish hundreds of articles on AIDS. In early 1981 the New England Journal 's editor instead referred Gottlieb to the U.S. Centers for Disease Control (CDC), the federal agency in Atlanta, Georgia, responsible for tracking diseases and controlling their spread.^[1]

The CDC's first report, published in its Morbidity and Mortality Weekly Report in June 1981, noted only that five young men in Los Angeles, "all active homosexuals," had been treated over the course of the past year for Pneumocystis carinii pneumonia (PCP).^[2] Two of the men had died. The microorganism that causes PCP is ubiquitous but is normally kept easily at bay by the body's immune system; therefore cases of PCP were exceedingly rare, restricted to people who were

immunosuppressed because of medical treatment (such as chemotherapy) or who for other reasons had severely malfunctioning immune systems. The CDC report zeroed in on the question of sexuality—"the fact that these patients were all homosexual"—to put forward two tentative hypotheses: that the PCP outbreak was associated with "some aspect of a homosexual lifestyle" or with "disease acquired through sexual contac." However, "the patients did not know each other and had no known common contacts or knowledge of sexual partners who had had similar illnesses."

A few weeks later, the CDC reported twenty-six cases (twenty in New York City and six in California) of young homosexual men suffering from Kaposi's sarcoma, a rare form of cancer normally found in elderly men. At least four of the men also had cases of PCP; eight of them had died.^[3] On the basis of this report, Dr. Lawrence Altman, medical reporter for the New York Times , wrote a short article about the cases of cancer in homosexuals.^[4] Appearing deep inside the newspaper on page A-20, the article sounded what would become one of the most common themes in mainstream media coverage of the epidemic: "The reporting doctors said that most cases had involved homosexual men who have had multiple and frequent sexual encounters with different partners, as many as ten sexual encounters each night up to four times a week." Soon after, Dr. Lawrence Mass, health writer for the New York Native —the most widely read gay newspaper in New York City and one of only a few to have a national readership—also addressed the question of promiscuity. In an article about "Cancer in the Gay Community," Mass wrote: "At this time, many feel that sexual frequency with a multiplicity of partners—what some would call promiscuity—is the single overriding risk factor. …"^[5]

Mass's article also explored a range of possible explanations for what he called (in quotes) "the gay cancer," including "an infectious or otherwise cancerous agent," but he noted that the "current consensus of informed opinion is that multiple factors are involved in the present outbreak of Kaposi's sarcoma among gay males." He quoted Dr. Donna Mildvan, chief of infectious diseases at Beth Israel Medical Center, who reported a colleague's belief that the outbreak of illnesses "has to do with the bombardment, the clustering of a whole range of infectious diseases among these patients which may be exhausting their immunodefensive capacities." And he cited Dr. Alvin Friedman-Kien, a professor of dermatology and microbiology at New York University Medical Center, who had examined some of the Kaposi's sarcoma

patients and who had speculated about the possible role of amyl nitrite or butyl nitrite inhalants. These inhalants, street drugs that were sold legally and were popular in gay male communities at the time, were often called "poppers" because consumers would pop open the packaging to release the fumes, which were then inhaled to produce a "rush" or to intensify orgasm. Nitrites were believed to have immunosuppressive effects. On the other hand, they had been prescribed to cardiac patients for years, and no unusual cases of PCP or Kaposi's sarcoma had ever been reported in that population.

By the beginning of 1982, a series of more detailed reports in medical journals such as the New England Journal^[6] was available as a source of additional information and speculation for researchers and medical practitioners, and for translation into the media, particularly the gay press. Researchers agreed that the telltale marker of these cases of immunosuppression was a deficiency in the numbers of "helper T cells"—or in other accounts, an abnormal ratio of helper T cells to suppressor T cells—types of white blood cells involved in the body's immune response.^[7] But questions of etiology and epidemiology were considerably more confusing. For one thing, it was already apparent that the "nationwide epidemic of immunodeficiency among male homosexuals"^[8] was in fact not restricted to gay men. According to the CDC's task force on the syndrome, 8 percent of the 159 cases were among heterosexuals, one of whom was a woman. In the pages of the New England Journal , Michael Gottlieb and his coauthors, the Los Angeles clinicians who had first reported the syndrome to the CDC, described finding the same syndrome in two exclusively heterosexual men, while Henry Masur and coauthors reported eleven cases of PCP in the New York area—five injection drug users, four gay men, and two men who were both.

Nonetheless, the focus of attention in all the medical literature remained squarely on the male homosexual sufferers, as evidenced by descriptors such as Brennan and Durack's "Gay Compromise Syndrome"^[9] and Masur et al.'s more euphemistic "Community-Acquired Pneumocystis Carinii Pneumonia."^[10] All speculation about causes proceeded from the premise of the centrality of male homosexuality. In Durack's words: "What clue does the link with homosexuality provide? Homosexual men, especially those who have many partners, are more likely than the general population to contract sexually transmitted diseases. Lesbians are not, and this apparent freedom, whatever its explanation, seems to extend to Kaposi's sarcoma and opportunistic

infections." Yet the assumption that the syndrome was somehow linked with homosexuality actually did little to immediately clarify the etiology, as Durack and others realized. Noting that "male homosexuals are at increased risk for the acquisition of common viral infections" such as cytomegalovirus (CMV), hepatitis B, and Epstein-Barr virus, Durack described the "obvious problem" with the hypothesis that CMV, or any of these viruses, might be the cause: "It does not explain why this syndrome is apparently new. Homosexuality is at least as old as history, and cytomegalovirus is presumably not a new pathogen. Were the homosexual contemporaries of Plato, Michelangelo, and Oscar Wilde subject to the risk of dying from opportunistic infections?"^[11] Durack's supposition was that "some new factor," such as poppers, "may have distorted the host-parasite relatinship." Concluding with some "frank speculation," Durack put forward a model essentially identical to the one Mildvan had proposed to the Native: that "the combined effects of persistent viral infection plus an adjuvant drug cause immunosuppression in some genetically predisposed men."

This model, which was sometimes called the "immune overload" or "antigen overload" hypothesis, represented the initial medical frame for understanding the epidemic: the syndrome was essentially linked to gay men, specifically to the "excesses" of the "homosexual lifestyle." The epidemic coincided historically, Newsweek suggested in the article "Diseases That Plague Gays," "with the burgeoning of bathhouses, gay bars and bookstores in major cities where homosexual men meet."^[12] Urban gay men, enjoying "life in the fast lane," had subjected themselves to so many sexually transmitted diseases, taken so many strong treatments to fight those diseases, and done so many recreational drugs that their immune systems had ultimately given up altogether, leaving their bodies open to the onslaught of a range of opportunistic infections. As one Harvard doctor is reported to have put it informally, "overindulgence in sex and drugs" and "the New York City lifestyle" were the culprits.^[13] What distinguished gay men from CMV-infected, sexually adventurous heterosexuals, and from cardiac patients inhaling amyl nitrite, and from the many patients who took strong antibiotic or antiparisitic drugs was, these experts suggested, that only gay men (or those gay men living in the "fast lane") confronted all these risks at once.