Reopening The Causation Controversy
From Deafening Silence to the Pages of Science (1987–1988)
How does a controversy that seemed to have been closed come to be reopened? What sort of tactics enable someone to disrupt the smooth transfer of knowledge from hypothesis to fact to common sense? The story of Peter Duesberg, who became the premier "HIV dissenter," is an enlightening one. Like other prominent researchers, Peter Duesberg proceeded to AIDS from prior work on retroviruses and their relation to cancer. Born in Germany in 1936, Duesberg received a Ph.D. in biochemistry from the University of Frankfurt; in 1970, he joined the faculty of the University of California at Berkeley in the Department of Molecular and Cell Biology.
In the 1970s, as millions of dollars were poured into the "War on Cancer," cancer research increasingly came to be dominated by what Joan Fujimura has called the "bandwagon" of oncogene theory. This theory held that certain genes within each cell had the potential to cause cancer. Closely tied to oncogenes were the cancer-causing retroviruses, which, it was argued, contained genes that could turn normal cells into cancer cells. Duesberg not only mapped the genetic structure of retroviruses but was the codiscoverer of the first known
oncogene, called src (pronounced "sark"). These accomplishments established him as a figure of note in his field.
To date, Duesberg has authored or coauthored more than 200 professional publications. A survey of the "Medline" database, which lists scientific publications that are medically relevant, shows more than 150 articles, literature reviews, monographs, and letters authored or coauthored by Duesberg. A study of the Science Citation Index , a crude but not uninformative indicator of a scientist's perceived importance in the eyes of peers, reveals that publications with Duesberg as first author have been frequently cited over the years, though particularly in the late 1970s. Between 1975 and 1979, for example, 76 of his publications were cited more than one thousand times. By comparison, during the same period, publications by his contemporary and colleague, Robert Gallo (that is, those with Gallo as first author), received over eight hundred citations. These figures put both scientists in the exceptional category, since articles listed in the Science Citation Index are cited on average only a handful of times a year—indeed, many are not cited at all.
Over the course of his career, Duesberg has received a number of awards and prizes, including being named the 1971 California Scientist of the Year. In 1986, the NIH awarded him an Outstanding Investigator Award, a special research grant for high achievers. In April of that same year Duesberg was elected into the National Academy of Sciences (NAS)—the cream of the crop, numbering about fifteen hundred of the top scientists in the United States. But Duesberg's career has not been without controversy. Indeed, in recent years, he had increasingly positioned himself as somewhat of a maverick, challenging the same conventional wisdom that he had earlier helped to construct. By the mid-1980s, Duesberg had become known as a dissenter from oncogene theory. "We have this nice idea of the oncogene model as some kind of switch" that turns on cancer, Duesberg told Forbes magazine, "but it has yet to be proved." In 1985 Duesberg published a formal challenge to oncogene theory in Science . Not everyone accepted Duesberg's argument, but neither did Duesberg suffer professional consequences as a result of his heterodox position. Indeed, both his Outstanding Investigator Grant and his induction into the NAS followed on the heels of his dissent.
Posing the Challenge
In many respects, the concerns Duesberg expressed in his article in Cancer Research , published in March 1987, were an extension of those he had voiced earlier. Entitled "Retroviruses as Carcinogens and Pathogens: Expectations and Reality," this sixteen-page review article with 278 references presented no original research but continued the argument that Duesberg had been trying to put forward: that retroviruses are simply not "the vessels of evil they have been labeled to be." In recent years, the general hypothesis that viruses were linked to cancer had been gaining ground, in part because many viruses (both retroviruses and ordinary DNA viruses) had been isolated from tumors and leukemias, particularly in animals. Duesberg pointed out, however, that many of these same viruses "were subsequently found to be widespread in healthy animals and humans." In his view, only a specific subset of these viruses were actually oncogenic (cancer-causing): those containing a class of genes called onc genes. Retroviruses lacking these onc genes, according to Duesberg, were harmless and ubiquitous; they could "coexist with their hosts without causing any pathogenic symptoms."
Without question, had Duesberg stopped there his article would have been ignored by everyone outside of a narrow specialist community. But Duesberg had another point to make, one that would occupy the final third of the article. The scientist later recalled: "As I was writing … AIDS just sort of literally exploded into the news media, and an article on retroviruses not at least taking a position [on] AIDS would have been rather incomplete. …" From Duesberg's perspective, the identification of the HIV retrovirus as the causal agent in AIDS was highly problematic. First, he pointed to the considerable disparity between the number of people estimated to be infected with HIV and the number of people who actually had AIDS. In the United States, where one to two million people were believed to be HIV positive, the annual incidence of AIDS among the virus-infected groups was only 0.3 percent. In Haiti and Africa, where estimates of infection ran even higher, the annual incidence was estimated at less than 0.01 percent. Since the introduction of the hypothesized agent so rarely appeared to cause disease, Duesberg claimed that Koch's third postulate had not been satisfied.
Second, Duesberg argued that it was implausible that a retrovirus would cause illness years after infection. He noted that many people
infected with HIV report having a brief, mononucleosis-like illness a few weeks after infection, and that this is what might reasonably be expected from a retrovirus. By contrast, the claim that HIV also caused AIDS some years later was hard to reconcile with the claim that HIV directly killed T cells: "We are faced with two bizarre options: Either 5 year old T cells die 5 years after infection or the offspring of originally infected T cells die in their 50th generation, assuming a generation time of one month for an average T cell." Furthermore, Duesberg noted that, in a study published in 1986 and conducted by Gallo and his associates, viral RNA was detected in only one of every ten thousand to one hundred thousand T cells in infected persons. In Duesberg's view, it was absurd to claim that a virus expressing itself in so few cells could be causing so much damage, since the body is constantly manufacturing new T cells. Even if the virus were to kill every ten-thousandth T cell every twenty-four hours, "it would hardly ever match or beat the natural rate of T-cell regeneration." Finally, Duesberg argued that there was no "simian model" for AIDS as required by a strict interpretation of Koch's postulates. Studies of chimpanzees and monkeys deliberately infected with HIV showed that these primates failed to develop a condition like AIDS (although such primates did develop viral antibodies, along with a mononucleosis syndrome similar to that in humans, shortly after infection).
What, then, did it mean to test HIV antibody positive? For Duesberg, it meant that one was protected against the effects of HIV: The purpose of antibodies is precisely to protect the body against the spread and expression of a pathogen. Having antibodies to HIV was therefore like being vaccinated against the virus. Until the immune system had created these antibodies, the person infected with HIV might suffer from the mononucleosis syndrome; but once the person tested positive for antibodies (normally within weeks after infection), he or she was safe—at least from HIV. HIV didn't harm its hosts; it was simply one of the many viral infections sustained by people with AIDS or at risk for AIDS, as was Epstein-Barr virus and CMV (found in 80 to 90 percent of them) and herpes (found in at least 75 percent). Perhaps AIDS was caused by one of these other infectious agents, perhaps it was caused by something other than a virus; Duesberg had no way of knowing. But HIV alone "is not sufficient to cause AIDS and … there is no evidence, besides its presence in a latent form, that it is necessary for AIDS."
A Controversy Takes Public Shape
Most scientific publications, sociologists of science have pointed out, are destined to die a lonely death. Given the tremendous number of publications that appear each year, it is inevitable that the average paper is ignored by the vast majority of scientists. Only a minority of papers are cited by many others; fewer still become the object of direct debate. As a general rule, one need not invoke a complicated explanatory apparatus to account for the fact that a scientific paper may sink beneath the surface of professional attention without causing much of a splash.
Duesberg's paper might have been particularly inclined in that direction because many of the points he was making were not especially new. Such questions as how the virus could cause the near-elimination of T-cells when only a few seemed to be infected had been raised before; this particular anomaly had made it into the National Academy of Sciences' Confronting AIDS and had even been discussed in the gay press. But arguably Duesberg's essay was different, and it might have been expected to generate a livelier response. It was written by an eminent scientist whose articles typically had been cited by dozens of other scientists each year. It was published in a respected journal. It had enormous implications if correct in its arguments. And it constituted nothing short of a declaration of war on some of the most prominent virologists in the world. Yet had it not been for the pressure exerted by outsiders who wrote about Duesberg in the alternative and mainstream press, the scientific community might never have addressed Duesberg's claims. Indeed, throughout the latter part of 1987 and early 1988, it was precisely the "AIDS establishment's" apparent avoidance that most incensed the HIV dissenters—and that provided them with their best ammunition.
The first apparent published mention of Duesberg's article came in a cover story by John Lauritsen in the June 1, 1987, issue of the New York Native . As the issue's cover advertised, the focus of the article was to encourage people with AIDS not to take the medication AZT. Recently approved for AIDS patients, AZT was believed to inhibit replication of the virus in infected cells by interfering with the process of reverse transcription. AZT, in other words, made sense as a treatment for AIDS only if AIDS was caused by HIV. This is precisely what Lauritsen disputed, and much of the article was devoted to the proposition that "HIV Is Not the Cause of AIDS."
With the discovery of the virus, "dogma rapidly came to prevail"; "all other research efforts were shunted aside, ostracized, under-funded," Lauritsen complained. Against this dogmatism, it was—until now—impossible for dissenters to make their voices heard: "Since 1984, there have been a few of us who stated in print that epidemiological evidence, together with the failure of HIV to fulfill any of Koch's postulates, made it most unlikely that HIV could be the sole cause of AIDS. … We were isolated. Some AIDS researchers did not believe in the 'AIDS virus' ideology, but, in the interests of self-preservation, they remained silent." But now that a prominent scientist had entered the fray, "all this has changed"; and the HIV dissenters could emerge from their isolation. As Latour has noted, "the power of [scientific] rhetoric is to make the dissenter feel lonely"; this is precisely what happens to the "average person" who tries to challenge highly technical scientific texts. The most obvious solution is to recruit credible allies who can provide rescue from isolation. Lauritsen had found just such an ally.
"Unless HIV's champions can do some very fancy explaining," Lauritsen concluded, "Duesberg's article has unambiguously relegated the 'AIDS virus' etiology to medical history's trash heap of falsified hypotheses." Insisting that "Gallo and the other 'AIDS virus' ideologues" must respond to Duesberg's article "fully and in detail," Lauritsen did his best to up the ante in the controversy: "If the Public Health Service and the media remain silent about Duesberg's article, and persist in expounding the discredited HIV mythology, then gay men will have cause to be gravely concerned. This would mean that the government and their confederates in the medical establishment are not acting in good faith, that nothing they say can be trusted, that their interests are hostile to ours. Their silence would raise the possibility of a horrible hidden agenda."
Soon after this article appeared, Lauritsen went to interview Duesberg at the NCI, where Duesberg was working while on sabbatical from the University of California. The interview was published both in the Native and, sometime later, in its more literary offshoot, Christopher Street; the Native ran photos of Gallo and Duesberg on its cover, with the headline "Which Man Is Right?" The interview recorded a fascinating duet between Duesberg and Lauritsen, with Duesberg voicing his support for Lauritsen's claim that AZT is poisonous ("It is a poison. It is cytotoxic.") and Lauritsen feeding Duesberg suggestions about what might cause AIDS. When Duesberg
shrugged off a direct question on causation ("Well, that's a difficult one. … I really wonder what it could be"), Lauritsen put forward the idea advanced earlier by various proponents of a multifactorial etiology that AIDS might have different causes in different groups. Duesberg chimed in: "Absolutely. And in Africa I don't think anybody knows what kind of AIDS exists, or whether AIDS exists. In the case of the drug users, I could well see that an infection of toxins—and the drugs are impure; no one knows where they come from—is hell for the immune system. And also medical injections—streptomycin or penicillin—are also not good on a regular basis. They are immunosuppressive themselves. Perhaps it is a simple question of lifestyle."
While assuring Duesberg that it was not incumbent on him to come up with an alternative hypothesis—"It's quite enough to have falsified theirs"—Lauritsen nonetheless pushed Duesberg's speculations further. He described for Duesberg what he called the "profile" of the average AIDS patient—a profile whose characteristics supposedly included long-term drug abuse, promiscuity, and repeated cases of sexually transmitted disease:
[Lauritsen: ] Looking at that profile … I think it would be surprising if such people did not become seriously sick from their lifestyle.
[Duesberg: ] I would be surprised, too. The number of contacts, the number of things they inject. You wonder how they could do it.
By the end of the interview, Duesberg appeared to be sliding out of his formal position of agnosticism and toward an endorsement of a lifestyle model similar to the immune overload hypothesis that had been so popular in the first years of the epidemic—indeed, a particularly judgmental version of that hypothesis.
According to James Kinsella's study of AIDS and the media, the Native's publisher, Chuck Ortleb, quickly took it upon himself to conduct a "phone-calling campaign" to promote Duesberg's arguments. But the Native —a paper whose fascination for unorthodox and speculative theories had left it with tarnished credibility even among its intended readership of gay men, let alone elsewhere—had only minimal power to spread the word about Duesberg or to evoke much alarm about a "horrible hidden agenda." Duesberg's claims did begin to circulate in gay communities; they were picked up, for example, by Charles Shively, writing about various alternative AIDS theories in Gay Community News . But only with Katie Leishman's September
1987 article in the popular magazine Atlantic Monthly did Peter Duesberg begin to hit the mainstream. Dubious of official pronouncements about the epidemic, Leishman's article ranged widely, exploring the possibilities of insect transmission and presenting a sympathetic portrait of Jane Teas's unappreciated efforts to push the African swine fever hypothesis. Near the end of the article, however, she also turned to Duesberg and Koch's postulates, noting that Duesberg "is so certain of his claim that he has offered to be inoculated with HIV."
Soon afterward, Duesberg made his first of what would prove to be several appearances in a British television documentary series called Dispatches . In an episode entitled "AIDS—The Unheard Voices," produced by a group called Meditel and broadcast on November 13, the narrators cited Duesberg to suggest that discrimination against anti-body positive people, however deplorable on its own terms, was particularly irrational if HIV were not even the true cause of AIDS. Though controversial in Britain, the show attracted little notice in the United States. Meanwhile, Harvey Bialy, the editor of a journal called Bio/Technology , had become interested in Duesberg's arguments, and Bialy invited Duesberg to write a summary of his Cancer Research article. Adopting a journalistic style, Duesberg complained that "the 'deadly AIDS virus' has been sold to the public as the cause of AIDS with the confidence and authority that is usually derived from absolute scientific proof."
In the immediate aftermath of the Leishman piece and Duesberg's own article in Bio/Technology , Duesberg began to be recognized in U.S. media circles as a credible and "quoteworthy" dissenter on the subject of AIDS. By the end of 1987, gay newspapers such as Gay Community News and San Francisco's Bay Area Reporter were publishing articles specifically about Duesberg—and about the failure of his colleagues to respond to him. "How come researchers continue to study HIV but have not refuted Duesberg's theory?" asked the subhead to the GCN article. "I've asked questions they apparently can't answer," Duesberg was quoted as saying.
Before long the story had acquired its own momentum. In January, Celia Farber, a journalist with the pop music magazine Spin , featured Duesberg in a long interview in her column called "AIDS: Words from the Front." In the interview, Duesberg suggested that researchers such as Gallo found themselves simply unable to retreat from their original claims because the "stakes are too high now": "Every progress report from their laboratories is discussed by Dan Rather and
Barbara Walters, Newsweek , and Time magazine. … To say that now, maybe, the antibody wasn't worth committing suicide for or burning houses for, would be very embarrassing." Even more provocatively, Duesberg delivered a stinging critique of the political economy of contemporary biomedical research, questioning the motives of AIDS researchers: "Scientists researching AIDS are much less inclined to ask scrutinizing questions about the etiology … of AIDS when they have invested huge sums of money on companies that make money on the hypothesis that HIV is the AIDS virus. … Gallo stands to make a lot of money from patent rights on this virus. His entire reputation depends on this virus. If HIV is not the cause of AIDS, there's nothing left for Gallo. If it's not a retrovirus, Gallo would become irrelevant."
As a reporter for the journal Science would later put it: "In the world of biomedical research, where ties to industry are pervasive but mentioning the fact is not, these are fighting words."
Interests, Investments, and "Fallen Angels"
Such charges made for good copy, but Duesberg's point was actually more subtle: virologists had "invested" in the HIV hypothesis—not just financially, though this was true in some cases, but personally, professionally, and psychologically. The following year, in a speech at a scientific gathering, Duesberg put forth this analysis as a full-fledged, revisionist history of retrovirology's desperate search for "clinical relevance." "On the basis of promises and expectations, the retrovirologists … have become the darlings of molecular and clinical biology in the last twenty years," Duesberg explained. Retroviruses were expected "to hold keys to cancer and other diseases," yet despite massive funding, the promise had not been fulfilled. Earlier in the century, virologists enjoyed spectacular successes against polio and smallpox. But "in the 1970's and 80's, virology suffered from the same fate that inorganic chemistry suffered in the early part of the century, when no new elements were left to be discovered!" Virology became "a thoroughly academic discipline, without significant clinical factors."
With more and more virologists at work using ever more sophisticated tools, it was inevitable that they would "succeed" in finding viruses that appeared to be linked to diseases that in fact have other causes, Duesberg argued. In this sense, virologists had become "the victims of their own weapons." Having found one such virus in AIDS
patients, virologists were now fanatically invested in the claim that the virus caused the syndrome: "An 'AIDS virus' is perhaps the last hope for the clinical relevance of the highly visible, highly decorated and powerful retrovirus establishment."
Duesberg was the first to note that it would have been simpler for him to pursue a sure thing, a "succession strategy" (to use Bourdieu's terminology), as opposed to a high-risk "subversion strategy" of scientific advancement. "Clearly the value of my very considerable investment in retroviruses would be much compounded by a clinically relevant retrovirus, which should thus motivate me to believe in HIV!" Duesberg told the gathering. "But since all work on retroviruses in the last 25 years has shown that latent retroviruses are harmless, and that virtually all retroviruses in wild animals and in humans are latent, I have lost faith in the central dogma of the program …," said Duesberg, characterizing himself as a "fallen angel, like Lucifer."
The Duesberg Story Goes Mainstream
With charges that AIDS experts were reaping millions of dollars from a discredited hypothesis, it didn't take long for the story to hit the newspapers. On January 7, the New York Post became the first daily newspaper to print an article specifically on the Duesberg controversy, called "AIDS Experts on Wrong Track: Top Doc." Writer Joe Nicholson, the Post 's medicine and science editor, cited Duesberg's offer to have himself injected with HIV, and he also quoted Gallo's protestation that "no serious scientist is interested in this." Nicholson paid considerable attention to Duesberg's credentials, noting that this "top scientist" had been studying viruses for twenty years, was a member of "the elite National Academy of Sciences," and had spend the preceding year on a scholarship at the NIH, "the world center of AIDS research." But Nicholson failed to mention that Duesberg's work at NIH was on cancer, not AIDS; nor did he justify his initial identification of his protagonist as "AIDS expert Dr. Peter Duesberg," given that Duesberg had neither conducted any laboratory research on AIDS nor had any professional contact with AIDS patients.
Perhaps predictably, the Post 's more upscale competitor was quick to follow up and to do so in a more skeptical vein. "A Solitary Dissenter Disputes Cause of AIDS," wrote the New York Times 's Philip Boffey, in a short (728-word) article published not in the front section but on the medical science page in section C. The article pitted
Duesberg's "provocative argument" against "virtually all of the leading scientists engaged in AIDS work [who] believe that Dr. Duesberg is wrong," and it quoted Anthony Fauci of NIH as saying: "The evidence that HIV causes AIDS is so overwhelming that it almost doesn't deserve discussion any more." Boffey also suggested that Duesberg's claims might be old hat: "AIDS experts insist that the issues raised by Dr. Duesberg have been considered at length within the scientific community. They cite plausible mechanisms whereby a tiny fraction of infected cells could disable vast numbers of additional cells."
A two thousand-word article by Joel Shurkin appearing soon afterward in the Los Angeles Times lent considerably more credibility to Duesberg's views. In an implicitly equalizing move, Shurkin referred to a debate between "two camps," the "dissidents" and the "AIDS Establishment," which "disagree not so much on the basis facts as on their interpretations." Shurkin's discussion of disagreement between scientists tended to convey a certain legitimacy upon Duesberg's arguments. For example, one AIDS researcher "who refused to be quoted by name" said that Duesberg was factually incorrect and that the virus had indeed been found in all patients. But another researcher "said the truth is somewhere in between." Such disagreement had the effect of suggesting that there was a legitimate spectrum of opinion on these questions and that Duesberg's views, however unpopular, were not beyond the reaches of plausible scientific theorizing.
Just as Duesberg's name was inching further into the mainstream media, Spin published a follow-up piece, an interview with Gallo in which the virologist responded—heatedly—to Duesberg's views. (William Booth, the news writer for Science , later characterized Gallo's "ranting and raving" as "bizarre," but added that the interview was tape-recorded without Gallo's knowledge. Should one keep an open mind on the question of the causation of AIDS? interviewer Anthony Liversidge, a New York City science writer, asked Gallo.
[Gallo: ] No. I don't think anybody needs to keep an open mind on that. It is silly, OK?
[Liversidge: ] Is there any flaw in [Duesberg's] logic that is easy for you to point out?
[Gallo: ] No. He's a good fellow. It's a useless interchange. Really totally useless. He's an organic chemist. I would never argue with him about electronic spin resonance in a molecule of organic compound.
Gallo went on to say, "This is just so trite that it is a waste of my goddamn time. I'm busy." Everyone knew that HIV was the cause of AIDS: "Call 5,000 scientists and ask."
Gallo's central complaint about his colleague was that Duesberg was simply not qualified to comment on the question. Or as Gallo bluntly told his interviewer: "Arguing with Peter is like you arguing with me." Furthermore, said Gallo, Duesberg had misinterpreted published evidence and ignored crucial arguments about the role of HIV in causing AIDS: "Hasn't Duesberg ever understood indirect mechanisms in cell killing? There are immune responses to the virus that destroy the proliferation of the T cell. That's crystal clear now. It is not just a matter of the virus going in and killing the cell directly. Does that take a genius?" Finally, Gallo was furious at Duesberg for failing to recognize the human consequences of his arguments: "Peter can do a lot of disservice. He has now indicated to people that they can go out and fuck around and get infected by this virus and not worry. That's the part where I am mad at Peter. Peter is joking about very serious matters that are going to alter some people's behavior."
Celia Farber capped off Liversidge's interview by appending an ironic comment, noting that a few years earlier, when Gallo introduced Duesberg at a university talk, he characterized Duesberg as having "a rare critical sense which often makes us look twice, then a third time, at a conclusion many of us believed to be foregone." And Farber quoted Duesberg's response to the Gallo interview: "I must say, of all the scientists I've known, Gallo's reactions are the most unscientific." In fact, Gallo was a convenient foil for Duesberg. Though this would change in the years to follow, at the moment Gallo was the AIDS establishment figure that everyone loved to hate. As rumors had spread that Gallo might have stolen Montagnier's virus, Gallo had come to be a symbol of expertise gone bad: untrustworthy, patronizing, and resentful of challenges. Just the past month, Gay Community News had spotlighted his attitude toward the AIDS activist group ACT UP in its "Quote of the Week" feature: "I don't care if you call it ACT UP, ACT OUT or ACT DOWN, you definitely don't have a scientific understanding of things," Gallo had reportedly told activists.
Gay Despair, Gay Suspicion
If gay men in early 1988 were apt to distrust Gallo, they were also inclined to be open to heretical views. This was a particular
moment in the history of the AIDS epidemic in gay communities, one marked both by profound desperation and the emergence of a new wave of militant activism. Gay men were wracked with frustration by the slow rate of progress in the development of treatments for AIDS, and those testing positive for HIV antibodies were increasingly pessimistic about their likelihood of avoiding illness and eventual death. Earlier on, the claim that AIDS was caused by a virus had resonated with gay concerns about avoiding discrimination and stigmatization. But this changed with reports by public health officials that the percentage of those infected with the virus who would go on to develop AIDS was not, as first believed, a small minority of 5 or 10 percent but in fact appeared to be at least 70 percent and might, in the absence of new treatments, rise as high as 100 percent. These tidings led to a deepening gloom between 1985 and 1988. For the largest and most established gay communities, where local newspapers routinely reported that one out of every two gay men probably was infected, such news can only be described as devastating. AZT at this point was prescribed only for people who already had AIDS (at a cost of about ten thousand dollars a year per person—and it was failing to keep them alive for very long). Some vocal spokespersons in gay communities, particularly in New York, argued that AZT did more harm than good. And there were no approved medications that antibody-positive people could take to keep them from progressing to an—apparently inevitable—AIDS diagnosis.
One response to these difficult times was a rebirth of activism, epitomized by the actions of groups like ACT UP and the San Francisco-based advocacy group Project Inform, that focused on eliminating the bottlenecks in the federal drug approval process, challenging the pharmaceutical houses over price-gouging for medications, and—as a popular slogan had it—getting "drugs into bodies." But a second response to the mood of desperation was a surge of interest in heretical views about AIDS. The AIDS establishment had failed to deliver; perhaps it was time to listen to some new voices. Understandably enough, cofactor theories were particularly attractive since they offered hope that not all those who were HIV antibody positive would actually develop AIDS. But more radical theories that disputed the HIV-AIDS link altogether had a certain appeal as well. Indeed, when Duesberg, along with Joan McKenna (director of an independent organization called the Institute for Thermobaric Studies, in Berkeley, and an advocate of the view that AIDS is actually a disguised form of syphilis),
was invited to speak at a public forum in San Francisco's heavily gay Castro district in January 1988, they were met by a standing-room-only crowd of six hundred. Many more were turned away at the door, according to San Francisco Chronicle reporter Randy Shilts, "reflecting the growing currency that a number of unconventional theories about the cause of AIDS are gaining in the gay community." Duesberg himself "received a hero's welcome" at the forum, in the words of an article published in the San Francisco Sentinel , a gay newsweekly.
That Duesberg should inspire the admiration of the gay masses was not without irony, given that the researcher at this point appeared to endorse the same immune overload hypothesis that, earlier in the epidemic, had often been characterized as homophobic and had been criticized for "blaming the victim." But initially people knew little about Duesberg. When interviewed by the Sentinel , Duesberg refused to give an alternative explanation for what causes AIDS, saying only, "I can't answer that." Shortly afterward, however, the Oakland Tribune quoted him as explaining: "I suspect we are dealing with an environmental lifestyle disease that has hit drug users, hemophiliacs and some gay communities the hardest. The trauma of anal intercourse could also be a factor. They could have used too many drugs, been too promiscuous, or had their immune systems weakened by venereal diseases, foreign antigens and antibiotics." More damningly, the February 2 Village Voice quoted Duesberg as saying that the epidemic was "caused by a lifestyle that was criminal twenty years ago." Days later, this remark became GCN 's "Quote of the Week."
As statements such as these became known, Duesberg lost any chance of sustaining large-scale support in gay communities. By February 1988, negative articles about Duesberg began to appear, including the Voice article, written by medical reporter Ann Fettner, called "Dealing with Duesberg: Bad Science Makes Strange Bedfellows." Duesberg's views on causation, Fettner wrote, constituted "a stunning regression to 1982, when everything under the sun, and gay practices in particular, were being blamed for the outbreak of the disease."
Yet even as Duesberg's stock was beginning to fall in gay communities, he was gaining considerable attention in the mass media and even in some government circles. On February 9, the refusal of mainstream AIDS researchers to confront Duesberg was blasted by Jack Anderson,
the syndicated columnist and well-known muckraker. According to Anderson, Harvey Bialy, the editor of Bio/Technology , had been planning a workshop called "How Does HIV Cause AIDS?" and a senior White House domestic policy analyst named Jim Warner had offered to cohost it. Warner was reported to be "frustrated about the inadequate response he had gotten to Duesberg's theory"; sponsorship by the White House "would guarantee the attendance of Gallo and other experts." Yet shortly before the conference was to take place, it was abruptly removed from the White House calendar. According to one editor at Bio/Technology , "The impression was that the pressure came from the NIH." When Anderson asked about the conference, Warner replied, "I can't talk about that." Anderson also noted that Gallo refused to return his phone calls.
The Establishment Hits Back
For the AIDS experts who thought Duesberg's arguments were pernicious nonsense, there were two choices, both of them fraught with some peril. They could continue to ignore Duesberg, at the risk of appearing closed-minded, imperious, or unscrupulous, and hope that he would eventually go away or that the media would simply lose interest. Or they could engage him directly and seek to show him up, at the risk of granting him further credibility or, at a minimum, publicity. "Many AIDS researchers refuse to comment publicly because they fear it will legitimize Duesberg," said NIH's Anthony Fauci, quoted in a March 1988 news article in Science .
Yet to many scientists, the political costs of ignoring Duesberg increasingly seemed to overshadow the risks inherent in engaging with him. Apparently in a move to undercut Duesberg's complaint of being marginalized, Dr. Frank Lilly of the Albert Einstein College of Medicine, the chairman (and the only openly gay member) of the President's Commission on the HIV Epidemic, an advisory body appointed by President Reagan the year before, responded to Duesberg's requests for an opportunity to make his views known by inviting him to testify at the commission's hearings in February. However, in what would prove to be a common theme in responses to Duesberg in the years to follow, commission members blasted Duesberg for the sin of playing to a public audience. One member, Dr. William Walsh, lectured Duesberg: "I would hope that you would press your theory within the scientific circles and not carry this uncertainty to the public.… Don't
confuse the public—don't confuse the poor people who are suffering with this disease." This appeal to Duesberg to avoid publicizing his dissent enraged Katie Leishman, who had promoted Duesberg earlier in the pages of Atlantic Monthly . She blasted the commission for its treatment of Duesberg, in an op-ed piece published in the Wall Street Journal entitled "The AIDS Debate That Isn't." Leishman reserved particular ire for Walsh: "The suggestion that the public and patients must be protected from confusion is not merely condescending but faintly sinister."
From the vantage point of the AIDS researchers and public health officials who were on the receiving end of all this criticism, the situation was rapidly getting out of hand. Into the fray stepped the American Foundation for AIDS Research (AmFAR), a prominent independent foundation that raised money for AIDS and dispensed it to a range of university-based and community-based research projects. With strong ties both to gay community representatives and mainstream researchers, AmFAR was well situated to play mediator. AmFAR sponsored a forum held at George Washington University in Washington, D.C., on April 9 and invited a range of panelists. Anthony Fauci, the most prominent government scientist present, had reservations about agreeing to participate but decided to come because "the scientific community can't afford to ignore [Duesberg] any longer."
At the forum, after Duesberg summarized what he termed the "paradoxes" of the HIV hypothesis, panelists and audience members hit back hard. Panelists insisted that Duesberg was simply wrong to say that viruses always cause disease within months and never do so in the presence of antibodies. And they noted that with the advent of a new technique for manipulating DNA called the polymerase chain reaction (PCR) it was now possible to find HIV in nearly 100 percent of samples from people with AIDS—though still not in every case, as Duesberg was quick to observe. As to the presence of HIV in so few T cells, Fauci stated that HIV also infected other immune system cells called macrophages and might hide in bone marrow cells. Fauci was particularly vehement in response to suggestions that AIDS really was linked to lifestyle: "What kind of risk behavior does the infant born of an infected mother have?" he asked. "And what about the 50-year-old woman who received a blood transfusion from an infected donor?"
Perhaps the most interesting data were presented by Warren Winkelstein, an epidemiologist from Berkeley's School of Public Health. Winkelstein's numbers came from the San Francisco Men's Health
Study, a prospective study of one thousand single men, gay and straight, twenty-five to fifty-four years old, who had been recruited by statistical sampling methods several years earlier, and who were reexamined every six months. One of several prominent "cohort studies" on HIV infection in the United States and around the world, the San Francisco Men's Health Study offered data of a kind that was simply not available at the time that closure had first been reached on the subject of HIV as the cause of AIDS.
In direct response to Duesberg's claims about Koch's postulates, Winkelstein organized his comments around what he described as a modern-day reformulation of those postulates, which consisted of five criteria. First, the "prevalence of disease should be significantly higher in those exposed to the factor than in unexposed controls." Winkelstein didn't have any data specifically on the prevalence of AIDS in the larger population, and his study (originally designed to examine progression to AIDS) had excluded from the outset any men already diagnosed with AIDS. But he did perform clinical and lab tests on his subjects upon entry, looking at a range of indicators considered to be predictors of AIDS, and the antibody-positive men had significantly higher prevalence rates for eighteen of the twenty-one indicators studied.
The second criterion was that incidence of disease (new cases) should be significantly higher in those exposed to the causal factor. This was precisely what Winkelstein had found. Thirty months into the study, of the 399 subjects who were antibody positive upon entry (all of them gay or bisexual), 13 percent had developed AIDS. Thirty-six subjects had seroconverted (become antibody positive) over the course of the thirty months; of these men, 8.3 percent had developed AIDS. And among 374 homosexual or bisexual men who remained seronegative throughout the thirty-month period, not a single person developed AIDS. Winkelstein estimated the probability that this association between antibody status and AIDS could have occurred by chance at less than one in a million.
According to the third criterion, a "spectrum of host responses" should follow exposure to the agent "along a logical biological gradient"; Winkelstein explained that this was demonstrated by the gradually declining T-cell counts in the antibody-positive group. Fourth, the disease must follow exposure to the causal agent: this criterion was confirmed by retrospective analysis of frozen sera that had been collected from gay men in San Francisco in 1978 for a hepatitis B vaccine study; analysis of the sera showed that gay men in San Francisco were
already infected before cases of the disease were known. And finally, elimination of the agent should decrease the incidence of cases: Winkelstein acknowledged that this criterion had yet to be satisfied, but he predicted that the decline in HIV transmission among gay men would eventually cause a corresponding decrease in the incidence of new AIDS cases.
During a lively question-and-answer period that followed the formal presentations, Anthony Liversidge, the interviewer who had elicited choice comments from Gallo, asked an important question about Winkelstein's data. Might not the same correlation between HIV infection and AIDS illness hold, asked Liversidge, if HIV were simply another opportunistic infection and not the actual cause of AIDS? Winkelstein acknowledged the point but argued that all the other evidence indicating a causal role for HIV made it highly unlikely that the correlation was "merely coincidental."
Opinion about the forum ranged widely in the gay and alternative press, from Ann Fettner's forthright denunciation of Duesberg as "homophobic" to Lauritsen's dismissal of the panel as a "kangaroo court." Interestingly, the AmFAR forum attracted a fair amount of attention in scientific publications but little in the mass media. (Possibly the mainstream reporters had lost interest once the apparent conspiracy of silence had ended, while by this point the larger scientific community was very much concerned about the potential ramifications of the controversy.) The position of reporters for both Science and Nature , the two most influential general science publications in the world, was that Duesberg had effectively been shown up. William Booth, writing his second article about Duesberg for Science , pointed to "vigorous head-shaking and audible groans" as Duesberg made his case. "If the … session accomplished anything," said Booth, "it was to confirm Duesberg as odd man out."
Writing in Nature , Rebecca Ward noted that the base of Duesberg's "credibility" all along had been "mainly among patient populations with the greatest interest in learning that HIV infection does not lead inevitably to a fatal disease," rather than among his scientific peers. At the forum, "Duesberg's quest for scientific credibility for his unorthodox theories … lost ground." Ward concluded with a prediction about the future course of the controversy, again distinguishing between Duesberg's popular credibility and his credibility in scientific circles: "Duesberg's theories will no doubt continue to receive attention from groups already mistrustful of the scientific establishment's
response to AIDS. But scientific acceptance for his ideas about AIDS, never very high, seems to be sinking." Little could Ward or Booth have guessed that, more than five years later, Duesberg would not only remain at the center of debate but would have garnered some backing from reputable scientists for his stance.
Part of Duesberg's capacity to attract credible support hinged on moving the debate more fully into respectable scientific circles. In April he published a brief restatement of his arguments in the British publication New Scientist (this was only weeks after the journal's editors, in an editorial called "And Yet It Kills," described Duesberg as "reveling in some peculiar form of intellectual self-indulgence"). But Duesberg's real coup was to force the AIDS establishment to debate him in the august pages of Science .
Here Duesberg was aided by Bialy, editor of Bio/Technology , who in March had written a letter to Dr. Daniel Koshland, the editor of Science and a colleague of Duesberg's at Berkeley: "I am very tired of hearing AIDS establishment scientists tell me they are 'too busy saving lives' to sit down and refute Peter's arguments [sic ] (although each one assures me they could 'do it in a minute if they had to'). … I urge you to use your offices to get Fauci or Gallo or Levy or Hazeltine [sic ], or Essex to prepare a rebuttal of Peter's arguments that is as carefully argued and referenced as his paper in Cancer Research." To simply dismiss Duesberg and hope he will eventually go away, concluded Bialy, "is a disservice and a disgrace to the very principles of scientific inquiry that you helped to teach me some twenty years ago."
Koshland solicited a short statement from Duesberg ("HIV Is Not the Cause of AIDS") and one coauthored by William Blattner (an NCI scientist), Gallo, and Temin ("HIV Causes AIDS") and ran the two statements, along with each party's response to the other, as a "Policy Forum" in the July 29, 1988, issue of Science . In their response to Duesberg, Blattner, Gallo, and Temin made what they saw as a crucial distinction between etiology (the cause of a disease) and pathogenesis (the processes by which the disease develops, including the mechanisms by which the etiologic agent causes the disease to be expressed). When he disputed whether HIV directly killed T cells and whether HIV was present in enough cells to cause immune system damage,
Duesberg was raising questions about pathogenesis. But while "there are many unanswered questions about the pathogenesis of AIDS, … they are not relevant to the conclusions that HIV causes AIDS." Recalling this turn in the debate some years later, Gallo would be adamant: "Never in the history of medicine have you had to solve pathogenesis before you could talk etiologically."
Why, then, were the authors so certain that HIV caused AIDS? In their contribution ("HIV Causes AIDS"), they made their case succinctly—though drawing less on virology, their area of expertise, than on epidemiological arguments: "The strongest evidence that HIV causes AIDS comes from prospective epidemiological studies that document the absolute requirement for HIV infection for the development of AIDS." Serology studies in the United States and around the world had demonstrated that wherever researchers found HIV, they would later find AIDS cases. The authors gave other examples. Over 95 percent of HIV-infected infants developed AIDS by the age of six, while their uninfected siblings never did. HIV, and not any other known infectious agent, was linked to transfusion-associated AIDS. And once HIV began to be screened out of the blood supply, the incidence of transfusion-associated AIDS began to decline, at least among new-borns who received transfusions. The authors provided one telling anecdote involving a baby that received a transfusion of HIV-tainted blood from a donor who later developed AIDS. The baby developed AIDS without any other risk factors, while the baby's mother and the baby's twin remained healthy. Blattner, Gallo, and Temin "conclude that there is overwhelming evidence that HIV causes AIDS."
Duesberg, however, was less than impressed by his colleagues' arguments. Epidemiology establishes correlations, Duesberg argued; it never proves causation. He went on to state than in order to establish a plausible causal model, researchers must make some sort of case that the putative cause is indeed capable of causing the disease in question. Pathogenesis, therefore, is never entirely dissociable from questions of etiology. In the past, when researchers have made causal claims in the absence of genetic or molecular evidence of activity, the results included, in Duesberg's words, "some of the most spectacular misdiagnoses in virology."
That said, Duesberg proceeded to address the epidemiological evidence presented by his interlocutors. First, he took exception to the claim that AIDS followed "in a predictable sequence" from HIV infection in all populations, noting once again that the incidence of AIDS,
expressed as a percentage of the group believed to be seropositive, seemed to vary widely between groups and between countries. Second, it was "presumptuous" to argue that HIV, rather than any other potential cause, was linked to AIDS in blood transfusion cases and in congenitally infected children. In the case of transfusions, how did we know that the recipients had no other risk factors during the years between infection and the development of AIDS? Besides, most of them were hemophiliacs, "persons with health risks … that are not representative of healthy individuals." As to the children, "96% had other health risks": their mothers were prostitutes or drug users, or the children had received blood products. So why assume that HIV was the culprit? These cases would be more convincing, Duesberg maintained, if the study authors had included a control group of matched antibody-negative persons and shown that they developed none of the AIDS indicator diseases or symptoms.
The Consequences of Controversy
What degree and what forms of credibility had Duesberg garnered in 1987 and 1988? On one hand, Duesberg's name and ideas, along with those of other dissenters, continued to surface in a variety of media and contexts. The gay magazine Christopher Street (owned, like the Native , by Chuck Ortleb) promoted alternative hypotheses of etiology in several more articles in 1988, and Duesberg entered the left-wing press with a positive treatment in the news-weekly In These Times . In a segment on AIDS treatments shown on the MacNeil/Lehrer News Hour , a San Francisco correspondent interviewed Duesberg, along with adversaries such as Winkelstein and Don Francis of the CDC. Jack Anderson wrote another column, focusing on Duesberg, Joseph Sonnabend, and Michael Callen, describing a "raging debate" over what caused AIDS, which was being enacted "behind the scenes of the AIDS crisis." Duesberg was also featured in a lengthy article in the popular scientific magazine Discover , which noted that he "doesn't look like a troublemaker" and that "even the Presidential Commission on AIDS recently listened to his testimony."
Moreover, there were signs throughout 1988 that Duesberg's views resonated with a small but not insignificant popular audience, particularly some gay men in cities throughout the United States. Volunteers at the San Francisco AIDS Foundation information hotline reported a
"small but growing number of calls about alternative theories regarding the cause of AIDS." And a number of activists were speaking out about the need to keep an open mind on the question of etiology. Michael Hirsch, founder of an advocacy group for HIV-positive people called Body Positive, was quoted in Christopher Street : "Body Positive feels very strongly that all possible theories and treatments should be explored. … Putting all our eggs in one basket is dangerous, as in the situation with HIV. AIDS has taught us that we have to assume responsibility for our own health. … We need to know about people like Duesberg and [Stephen] Caiazza [a proponent of the syphilis theory of AIDS causation], but the media is not going to tell us about them."
Finally, "AIDS establishment" scientists were increasingly forced, however reluctantly, to acknowledge the existence of controversy. "What is the evidence that HIV-I is the cause of AIDS? It is late in the history of HIV-I to bring this point up for review," complained Gallo in an overview of "HIV—The Cause of AIDS" published in 1988 in the Journal of Acquired Immune Deficiency Syndromes . "However, in the past year or so, those of us in the United States have seen the HIV-I cause of AIDS conclusion repetitiously, though not always thoughtfully, attacked by a few colleagues." The acceptance of their views, warned Gallo, "may lead to an irresponsible, carefree spread of the virus and progressive decline in the credibility of scientists, physicians, and health care workers."
But the most authoritative public representations of knowledge about AIDS showed little impact of the so-called "raging debate" beyond, in certain quarters, a perceptible hardening of positions. The 1988 update to the National Academy of Sciences' Confronting AIDS is instructive. In 1986, the report had questioned whether the term "AIDS" was still adequate to capture the full spectrum of conditions associated with HIV infection; by 1988, the authors were unequivocal: the actual disease being fought was the disease of HIV infection. "It is now clear that the 'AIDS epidemic' is really an epidemic of HIV infection, and when referring to the epidemic in general, we use the terms interchangeably." In 1986, the NAS authors had reviewed, without much passion, the evidence in support of the HIV hypothesis; but the 1988 update declared in boldface type: "The committee believes that the evidence that HIV causes AIDS is scientifically conclusive." The establishment line was presented without mention of dissent—yet the adamant tone of the presentation in comparison to that of two years
earlier suggested that Duesberg's opposition had mobilized scientific experts.
Another marker of authoritative knowledge was the report of the presidential commission, which appeared in 1988. Like the NAS, the commission tended toward a phenomenological merging of "HIV" and "AIDS," declaring in its "Executive Summary" that "the term 'AIDS' is 'obsolete.'" The commission maintained that "'HIV infection' more correctly defines the problem. The medical, public health, political, and community leadership must focus on the full course of HIV infection rather than concentrating on later stages of the disease." Such formulations, of course, left little room for doubt concerning the etiologic role of HIV. The phrase "HIV disease," the codification into language of a hegemonic belief, made it harder even to think the question of whether causality had been proven.
Consolidation and Refinement (1989–1991)
"Red Flags" at the Academy
Over the course of the next several years, Duesberg remained the most prominent of the "HIV heretics," and he engaged in a persistent struggle to keep his views before the eyes of a professional readership. By June 1988, before Science 's "Policy Forum" had even appeared in print, Duesberg had submitted another article, this time to the Proceedings of the National Academy of Sciences (PNAS ). The house organ of the same academy that had published Confronting AIDS, PNAS was unlikely to be receptive to Duesberg's views. Yet by virtue of having been inducted into the academy a few years earlier, Duesberg enjoyed a privilege unique in the world of scientific research: NAS members generally could publish in the Proceedings without submitting themselves to the rigors of formal, anonymous peer review. Instead, members were asked simply to show each submission to a knowledgeable colleague who could vouch for its worth and validity.
This special treatment was discretionary, however, and in practice PNAS suspended the policy in the case of manuscripts that raised the "red flag"—the managing editor's term for "things that have the possibility of ending up on the front page of the Washington Post ." The ambiguities of this policy had caused headaches for PNAS editors before, most notably in 1972, when the renowned scientist and academy member Linus Pauling was prevented from asserting in the journal's
pages that vitamin C could cure cancer. As Evelleen Richards has argued in a study of the Pauling controversy, PNAS 's gatekeeping practices reveal in particularly stark outline the "social character of the publication process" in science.
Duesberg's article was eventually published by PNAS in February 1989, with a second one to follow two years later —yet the behind-the-scenes politicking attracted more attention than the articles themselves. Writing another news report for Science , William Booth described the "60 pages of correspondence" generated by "nearly 8 months of protracted, often testy, occasionally humorous negotiations" between Duesberg and Igor Dawid, the chairman of the editorial board. Dawid's predecessor, Maxine Singer, had rejected Duesberg's 1988 submission outright on the grounds that it repeated the arguments in Cancer Research and therefore lacked originality. Maintaining that the article had one hundred new references, Duesberg pressed his case, and Dawid, having taken over from Singer, passed the paper along for peer review by three anonymous reviewers, all of whom raised objections to the manuscript. "For the next 6 weeks," said Booth, "by express mail and by fax machine, Duesberg and Dawid duked it out," with Duesberg agreeing to a number of changes and clarifications. Booth suggested that Dawid eventually surrendered to the inevitable; he quoted from Dawid's correspondence: "At this state of protracted discussion I shall not insist here—if you wish to make these unsupported, vague, and prejudicial statements in print, so be it. But I cannot see how this could be convincing to any scientifically trained reader." In truth, what Dawid may have failed to see was that Duesberg could later use the very fact of having been published in the Proceedings as capital to advance his position.
Anthony Liversidge, writing a longer piece for The Scientist , raised the more nettlesome questions about "just what constitutes fair play in the science publishing arena." On one hand, it seemed problematic to have a special publication policy for academy members that was applied only selectively. On the other hand, what was the point of insisting that the paper be peer reviewed if in the end the journal was going to publish it anyway, despite the fact that all three reviews were unfavorable? Liversidge quoted Walter Gilbert, a professor of molecular biology at Harvard and winner of the 1980 Nobel Prize for his work on DNA sequencing methods, who criticized the PNAS editors for giving Duesberg "too much of a rough going." But opponents of Duesberg, such as Gallo—who said he hadn't read the paper because "I have
to work for a living"—simply chalked up the incident to the peculiarities of PNAS 's policies: "The Proceedings is a great journal, but you can't stop a member from publishing unless it is totally off the wall."
Arenas of Controversy
Besides the articles in the Proceedings , there were three other important arenas in which the controversy was played out in the period from 1989 to 1991. First, debate about the etiology of AIDS invaded the International Conference on AIDS in San Francisco in 1990: at a specially convened session, Luc Montagnier placed himself in the camp of Shyh-Ching Lo by announcing that he had found a mycoplasma in a significant percentage of AIDS patients (thirty-seven out of ninety-seven). Montagnier proposed that the mycoplasma might be a necessary cofactor that acts in conjunction with HIV to cause AIDS. The antibiotic tetracycline, by killing the mycoplasma, might therefore be of benefit to AIDS patients. In particular, Montagnier thought that a cofactor such as mycoplasma could explain how HIV caused the destruction of the immune system, given that the virus was not found in many cells and given that the virus did not appear to kill cells directly. U.S. scientists were dismissive of Montagnier's new hypothesis. "Dr. Montagnier is out on a limb," said James Curran, director of the AIDS program at the CDC. Some scientists expressed the view that Montagnier was squandering his credibility; in the words of the New York Times , they "[wondered] aloud why Dr. Montagnier would risk his professional standing by backing such a theory without more evidence."
Later, HIV dissenters would reap support by pointing to the way the "orthodox" had silenced one of their own when he dared to step out of line. Duesberg would indirectly benefit from Montagnier's intervention, effectively riding on the coattails of the French scientist in the mainstream media. At the 1990 conference, however, this San Francisco Bay Area resident was far from the action. At a hotel two blocks away from the official conference, Duesberg addressed a symposium on alternative treatments for AIDS. A dismissive report by a Reuters correspondent described the mix of alternative treatments proposed by the panelists as "a witch's cauldron of boiling blood, mushrooms and mistletoe," and associated Duesberg with this imagery by noting that "his contentious theory … has brought charges of 'quackery' against him."
Duesberg fared better in a different arena, a British television documentary called "The AIDS Catch," produced by Joan Shenton and Meditel Productions, who had already featured Duesberg once, in 1988. Shown on British television in June, just before the International Conference, the program ignited a firestorm in Britain by presenting the world of AIDS as seen through the eyes of the HIV dissenters. As the narrator declared: "Everything we currently accept about AIDS can be turned on its head." The narrator presented a range of questionable statistics, noting that in any one year in the United States, only a tiny fraction (1.5 percent) of HIV positives develop AIDS, but not indicating how many HIV positives develop AIDS over longer periods of time. In an argument against AZT, the show also claimed that "so far no one has lived longer than three years" on the drug, without explaining that AZT had not been in general use for much longer than that and that only the sickest patients had initially been prescribed it.
"The AIDS Catch" assembled in one place nearly all of the key dissenters. Duesberg was featured prominently on the show, along with Sonnabend and Callen. Lauritsen presented his observations on gay male culture, telling the interviewer: "They might take six different drugs in the course of an evening." British writer Jad Adams, whose pro-Duesberg book, AIDS: The HIV Myth , was published the previous year, proposed psychological reasons for why "people want to believe in HIV." Gordon Stewart, an epidemiologist from Glasgow who supported the immune overload hypothesis, discussed poppers, which he described as "very toxic indeed." The program also featured Walter Gilbert, the Nobel Prize-winning Harvard molecular biologist who had criticized PNAS in the interview with Liversidge. Gilbert was persuaded by the substance of many of Duesberg's arguments, but he made his most forceful point with reference to what he called "democratic theory," arguing that scientific progress comes about through the clash of opposing ideas: "The great lesson of history is that knowledge develops through the conflict of viewpoints, that if you have simply a consensus view, it generally stultifies, it fails to see the problems of that consensus; and it depends on the existence of critics to break up that iceberg and to permit knowledge to develop. This is, in fact, one of the underpinnings of democratic theory; it's one of the basic reasons that we believe in notions of free speech; and it's one of the great forces in terms of intellectual development."
The Heritage Foundation
and the "Risk-Aids Hypothesis"
The third crucial arena for dissenting views during this time period was a lengthy (8,900-word) cover story by Duesberg and Bryan J. Ellison published in the summer 1990 issue of Policy Review, a publication of the Heritage Foundation, the well-known, right-wing think tank. The essay was actually written by Ellison, a politically conservative graduate student in Duesberg's department and self-appointed popularizer of Duesberg's views. "Scientists weren't going to listen to him. They couldn't afford to," Ellison explained. "So I realized he had to take his case to the general public." The article became, in the editor's words, "one of the three or four most-talked-about articles in the history of the magazine, … [eliciting] more letters to the editor than any in Policy Review 's history." The article also incorporated the first formal presentation by Duesberg of an alternative explanation for the etiology of AIDS, which Duesberg and Ellison dubbed the "risk-AIDS hypothesis."
The biographical note explained that Duesberg had published critiques of the accepted "virus-AIDS hypothesis" in a number of scientific journals, such as Cancer Research and the Proceedings of the National Academy of Sciences . In this way, Duesberg's accumulated scientific credibility was now converted into credibility in a different, more public forum. However, a chief strategy of the Policy Review article was to present the critique not as Duesberg's personal crusade, but as the clamor of a growing chorus, within which Duesberg was just one voice. The article therefore attributed dissenting views whenever possible to people like Walter Gilbert and Harvey Bialy. More generally, it described "an increasing number of medical scientists and physicians [who] have been questioning whether HIV actually does cause AIDS"; the article linked together those who said HIV could not play a role, those who said HIV had not conclusively been proven to play a role, and those who argued for cofactors. The reader might never have heard of this expanding group, the authors explained, because "most of these doubters prefer not to be quoted, out of fear of losing research funding or of disapproval by peers." Skepticism therefore remained a minority position "due largely to inadequate attention provided by media sources."
In the article, Duesberg and Ellison reiterated their standard arguments but also presented in expanded form a criticism that Duesberg
had not previously discussed in print in great detail: they argued that the notion that HIV caused AIDS was based fundamentally on a tautology. According to the CDC's 1987 update of its surveillance definition, AIDS was (usually) diagnosed by a positive HIV antibody test, in the presence of one or more diseases from a list: "The disease-list includes not only Kaposi's sarcoma and P. carinii pneumonia, but also tuberculosis, cytomegalovirus, herpes, diarrhea, candidiasis, lymphoma, dementia, and many other diseases. If any of these very different diseases is found alone, it is likely to be diagnosed under its classical name. If the same condition is found alongside antibodies against HIV, it is called AIDS. The correlation between AIDS and HIV is thus an artifact of the definition itself." Perfectly ordinary illnesses got stuck with the label "AIDS" if the ill person happened to be HIV positive; then researchers would turn around and say that, since everyone with AIDS was HIV positive, HIV must be the cause. This was an interesting argument, one which threw into question not only the logic of the causal claim but also the very status of "AIDS" as a legitimate disease category. It was an argument that Duesberg would often repeat in subsequent years; but it was somewhat disingenuous as posed.
Although the CDC's 1987 definition listed a number of diseases that, in an HIV-infected person, would result in an AIDS diagnosis, many of them—like Pneumocystis carinii pneumonia, toxoplasmosis, and cryptosporidiosis, diseases typical of AIDS patients—were relatively rare in general. Others, like CMV, herpes, and candidiasis, were indeed common, but in these cases the CDC's specifications went further, requiring that the conditions be present in parts of the body where these infections normally did not take root. Similarly, tuberculosis was on the list—but only if it involved at least one site other than the lungs. Diarrhea, of course, was not on the list; Duesberg and Ellison were referring casually to what the CDC called the "HIV wasting syndrome," defined as "profound involuntary weight loss > 10% of baseline body weight plus either chronic diarrhea (at least two loose stools per day for > 30 days) or chronic weakness and documented fever (for > 30 days, intermittent or constant) in the absence of a concurrent illness or condition other than HIV infection that could explain the findings. …" The diagnostic definition of AIDS-related dementia was similarly restrictive. Overall, clinical markers of AIDS were rare diseases and conditions generally not seen in people who were not HIV positive. By failing to explain these details of the CDC's diagnostic algorithm and by suggesting that ordinary diarrhea and tuberculosis
were being taken as markers of AIDS, Duesberg and Ellison were misleading their lay audience.
But at the same time, Duesberg and Ellison presented arguments to counter the assumption that the rare AIDS diseases, like Kaposi's sarcoma and PCP, were in fact so rare. They maintained that "not only have all 25 of these AIDS conditions existed for decades at a low level in the population, but HIV-free instances of the same diseases are still being diagnosed." They also described a recent letter to Lancet by Robert Root-Bernstein, an associate professor of physiology at Michigan State University and recipient of a MacArthur fellowship—one of the so-called "genius grants" provided, no-strings-attached, to individuals in a variety of fields who have been deemed unusually promising. Root-Bernstein's review of the medical literature had led him to conclude that perhaps 15 to 20 percent of all Kaposi's sarcoma cases before 1979 fit the pattern generally believed to have arisen only with the AIDS epidemic: young victims with a short survival time. Citing Sonnabend, Root-Bernstein had written: "Several hypotheses must be entertained—that AIDS is not new; that HIV is only one of several possible causes of AIDS; or that HIV is itself a new, opportunistic infection that takes advantage of previously immunosuppressed individuals."
The existence of "AIDS" diseases in people who are not antibody positive, in Duesberg and Ellison's view, was evidence for their alternative hypothesis, the risk-AIDS hypothesis. They proposed "that the AIDS diseases are entirely separate conditions caused by a variety of factors, most of which have in common only that they involve risk behavior." But like Sonnabend and others who had trod this path before them, the authors recognized that "a risk hypothesis must explain the recent increases in the various AIDS diseases, and why these have all been concentrated in particular risk groups." So Duesberg and Ellison put forward a potpourri of potential causes of the AIDS marker illnesses, linking Kaposi's sarcoma with popper use by gay men; AIDS dementia with psychoactive drugs and syphilis; and the wasting syndrome, "found most heavily in African AIDS patients," with "the extremes of malnutrition and the lack of sanitation on most of that continent," compounded in recent years by "wars and totalitarian regimes."
Many of these arguments were widely familiar from debates early in the epidemic: the claims about African health conditions, for example, mirror Sonnabend's speculations about Haitians in 1983. And indeed, to explain the systemic failure of immune response that is
characteristic of AIDS, Duesberg and Ellison's article explicitly endorsed the immune overload hypothesis, incorporating it within their risk-AIDS hypothesis: "Joseph Sonnabend, a New York physician who founded the journal AIDS Research in 1983, has pointed out that repeated, constant infections may eventually overload the immune system, causing its failure; still worse are simultaneous infections by two or more diseases." Duesberg and Ellison also pointed to heavy drug use as a major cause of immunosuppression. They claimed that abuse of alcohol, heroin, cocaine, marijuana, Valium, and amphetamines "can all be found as part of the life histories of many AIDS patients"; "when combined with regular and prolonged malnutrition, as is done with many active homosexuals and with heroin addicts, this can lead to complete immune collapse." To round out the picture, the authors noted the long-term immunosuppressive effects of antibiotics and claim that "active homosexuals … often [take] large amounts of tetracycline and other antibiotics each evening before entering the bath houses."
Duesberg and Ellison didn't provide any sources for their ethnographic data, and in interviews both of them acknowledged having little direct knowledge of gay life despite its vibrant expression in San Francisco, only miles from the Berkeley campus. In part the authors were drawing on early medical claims about "how the gay lifestyle" was related to the epidemic of immune suppression, which in turn borrowed from earlier and contemporary medical literature on gay men who attended clinics for treatment of sexually transmitted diseases (see chapter 1). Communication with John Lauritsen may also have played its part in shaping their biased understandings of gay male behavior. In a letter to Duesberg written just a few months earlier, Lauritsen had characterized the Mineshaft, the Saint, and St. Mark's Baths—the most prominent New York City venues for uninhibited gay male sex in the years before the epidemic—as "hell-holes which were the arenas for truly psychopathic drug abuse as obligatory tribal ritual."
Gay men and injection drug users had always been the focus of immune overload theories. But no one promoting such a perspective in 1990 could avoid discussion of the other "risk groups," and Duesberg and Ellison understood this. They explained (again echoing Sonnabend's claims from seven years earlier) that blood transfusion recipients were at risk of developing immunodeficiency because of pathogens present in transfused blood. Moreover, people receiving blood
transfusions typically did so because they were already quite ill or had undergone surgery, and both the trauma of the surgical procedure and the anesthesia could have immunosuppressive effects. In fact, Duesberg and Ellison claimed, "with or without HIV infection, half of all [transfusion] recipients do not survive their first year after transfusion." Similarly they noted that "hemophilia has always been a fatal condition," and that the blood products received by its sufferers were immunosuppressive. Finally, cases of AIDS in infants could be traced to "combinations of most of the above risk factors"; 95 percent of these babies were born to mothers who either used drugs or were sex partners of drug users, or had received transfusions, or had hemophilia. According to Duesberg and Ellison: "The risk behavior of many of their mothers has reached these victims, but their conditions are renamed AIDS when in the presence of antibodies against HIV."
In the conclusion to the article, Duesberg and Ellison turned to the policy implications of their argument. "The most urgent of these," they said, concerned the widespread administration of AZT. This powerful drug worked by inhibiting the replication of the virus, but "by doing this the drug also kills all actively growing cells in the patient," including immune system cells. If the virus was harmless, as the authors maintained, then "inhibiting HIV would accomplish nothing, while AZT actually produces the very immune suppression it is supposed to prevent." AZT, by this view, was just another harmful drug—like heroin, cocaine, and poppers—that contributed to immune overload. Second, the risk-AIDS hypothesis called into question the existing AIDS education strategies. Condoms and sterile needles were fine if the goal was to prevent hepatitis and other infectious diseases. But the hazard of these programs, Duesberg and Ellison maintained, was that they lulled the practitioners of risk behaviors into a false sense of security. By failing to "[emphasize] the danger of the risk behavior itself—particularly drug-taking—[these programs] may inadvertently encourage spread of the disease."
The HIV hypothesis "has not yet saved a single life, despite federal spending of $3 billion per year," Duesberg and Ellison reminded their readers in closing. Instead of sinking more money down the same hole, the government should begin funding "studies on the causes of the separate AIDS-diseases and their appropriate therapies." The rest of the $3 billion "might then be saved and returned to the taxpayers," wrote the authors in a suggestion that presumably did not clash with the conservative agenda of Policy Review .
The next issue of the magazine was devoted to letters in response to Duesberg and Ellison—the total length of the letter section was over 13,000 words, one and a half times the length of the original article. Both the establishment and the dissenters were well represented. Howard Temin stressed the "tragic" pediatric evidence: in one study, fifteen of sixteen HIV-infected children of infected mothers had AIDS or pre-AIDS symptoms, while none of thirty-nine uninfected children of infected mothers showed signs of illness. Wrote Temin: "Duesberg and Ellison state that 'the risk behavior of many of their mothers has reached these victims.' It is clear that what reached the children was HIV." Warren Winkelstein, the Berkeley epidemiologist, wrote in with the most recent results from the ongoing San Francisco Men's Health Study. Out of 386 homosexual men who had been HIV positive when entering the study six years before, 140 (36 percent) had developed AIDS, and the majority of them had died. Forty homosexual men had become infected since entering the study, and 2 (5 percent) had developed AIDS. But of 370 homosexual men who had remained uninfected, none developed AIDS.
An interesting letter came from Michael Fumento, who had written a popular book called The Myth of Heterosexual AIDS . Each of them a controversial figure, Duesberg and Fumento shared the belief that AIDS was a "risk group disease" and not a threat to the general population. But they were on opposite sides when it came to the etiological debate. Noting that his "initial reaction to anyone challenging the AIDS industry in any way is favorable," Fumento continued: "but in the case of Peter Duesberg and his co-author Bryan Ellison, I really must demur." After raising objections to Duesberg and Ellison's arguments, Fumento threw down the gauntlet: "What I would suggest, in perfect seriousness, is that before the authors write another article suggesting that it is perfectly okay for HIV-infected persons to have unprotected sex with uninfected persons or vice-versa, that they, in a public forum, inject themselves with HIV. Apparently Duesberg has hinted he may do it; I think he should go beyond that. Readers have a right to know just how much faith the authors have in their own theory."
Duesberg and Ellison were given the last word, and they had plenty to say. They began by expressing their pleasure that "the debate that should have occurred … years ago" was finally taking place. They then launched into a critique of the cohort studies that Winkelstein
and other letter writers had cited as definitive. The existing studies proved nothing, in Duesberg and Ellison's view, because they failed to demonstrate that illness was the consequence of HIV, not risk behavior. A controlled study actually designed to distinguish between the two causal hypotheses would be set up quite differently. It would compare two large groups of people, HIV positives and HIV negatives. But the two groups would be carefully matched for "every health risk that might possibly be involved in the various AIDS diseases."
Duesberg and Ellison also responded to various arguments that letter writers had raised—about babies with AIDS, about wives of hemophiliacs, about needle-stick injuries. Only "media sensationalism," they argued, could convince people that wives of hemophiliacs were at great risk of AIDS if they had no other risk factors. Those cases that had occurred were quite explainable: "Since AIDS is merely, by definition, a list of old diseases that are renamed when in the presence of antibodies against HIV, one should not be surprised to find an occasional such wife who happens to contract HIV and, coincidentally, one of the many diseases on the AIDS list." A controlled study, they believed, would show that HIV-positive wives developed AIDS indicator diseases at the same rate as HIV-negative wives.
The real problem, in Duesberg and Ellison's view, was that the established AIDS researchers abandoned scientific principles when it suited their interests. Instead of controlled studies, these researchers invoked anecdotal evidence. When Koch's postulates failed them, they "casually try to abandon those timetested, commonsensical" rules of scientific method. And "when all else fails," they started "changing the rules," "rather than bringing the hypothesis into question," as real scientists were supposed to do. To explain why so few antibody-positive people had AIDS, "a latent period first had to be invented, then extended to its present, and still growing, total of 10 to 11 years." Duesberg and Ellison concluded by declaring themselves "quite willing to carry out the Fumento test." But their degree of interest in doing so depended on the attention it could attract to their cause: "If he will arrange for sufficient national publicity, if he would be convinced by our action, and if he will thereafter help us bring exposure to our viewpoint, we will indeed be quite happy to have ourselves publicly injected with HIV. Perhaps Fumento will also be willing to check on our health status in the year 2000, or after whatever additional time is eventually added to the virus' latent period."
"The Impact of the Truck"
The International AIDS Conferences, the documentary "The AIDS Catch," and the Policy Review article and ensuing debate were three arenas in which the causation controversy bubbled into clear public view in 1989, 1990, and 1991. Elsewhere, the controversy was not invisible, but it simmered more quietly. In scientific communities and gay communities, in the mainstream press and the alternative press, various players pushed their claims, seeking to establish their credibility or undercut that of others. In the process, dissenters who had been predicted to fade into oblivion instead demonstrated their staying power. This quiet jockeying for position would set the stage for a fierce resurgence of the causation controversy in 1992.
Formal scientific debate continued throughout this period. One exchange that was followed closely by insiders took place in the Journal of Acquired Immune Deficiency Syndromes between Duesberg and Alfred Evans of the Department of Epidemiology and Public Health of the Yale University School of Medicine. Evans was an authority on Koch's postulates and had been writing about them since the 1970s; he emphasized that "the postulates of causation have changed and will continue to change with the new technology and new concepts of pathogenesis." Revealing his historical bent, Evans also noted that Duesberg's offer to be injected with HIV was reminiscent of a similar act by German researcher Max von Pettenkofer. In 1892 at the age of seventy-four, von Pettenkofer drank a milliliter of "a fresh culture of cholera vibrio derived from a fatal case" to attempt to prove his point that cofactors were required to cause the disease. Von Pettenkofer was lucky: he didn't develop serious cholera, although he did have gas and diarrhea for a week afterwards. Evans urged Duesberg not to follow in von Pettenkofer's footsteps.
Duesberg also published articles and letters in Science, Nature, The Scientist , the New England Journal of Medicine , and the Pasteur Institute's Research in Immunology , among other places. In these publications Duesberg tended to restate his earlier views while responding to critics. Increasingly, he invoked other dissenters as allies in his writings, citing work by scientist and nonscientist alike—Jad Adams, Celia Farber, John Lauritsen, Harry Rubin, Joseph Sonnabend, Katie Leishman, Anthony Liversidge, and Gordon Stewart. Robert Root-Bernstein, the young physiologist whose letter to Lancet had attracted Duesberg's notice, also kept busy. He expanded on his position in a
1990 article in a journal called Perspectives in Biology and Medicine . Although careful to maintain an official position of agnosticism, Root-Bernstein stressed the prevalence of risk factors among people with AIDS—chronic or repeated infectious diseases, drug use, anesthetics, antibiotics, semen exposure, blood exposure, and malnutrition.
For the average layperson not inclined to peruse the pages of the medical and scientific journals, the easiest place to learn about the HIV dissidents during this time period was, ironically enough, the pages of Robert Gallo's Virus Hunting , a book for the general reader published in 1991. Though in the past Gallo had declared himself "too busy" even to bother reading Duesberg's articles, this book included an entire chapter entitled "About Causes of Disease (and, in Particular, Why HIV Is the Cause of AIDS)"—a chapter that, amid discussion of Montagnier's mycoplasmas and Root-Bernstein's risk arguments, devoted a full ten pages to refuting Peter Duesberg.
"When are we ready to say that we know the cause of a disease?" asked Gallo, taking aim at the crux of the controversy. "To a greater extent than we might want to believe, there are few hard-and-fast rules [and] certainly no cookbook recipe to follow," he added, noting that Robert Koch "has been taken too literally and too seriously for too long." But most diseases did have a sine qua non , though other factors might contribute to the severity, speed of onset, or likelihood of development. Gallo offered the analogy of head injury in the case of a truck that crashes into a group of bicyclists, some of whom are wearing helmets, some of whom hit concrete, and some of whom are clad in red shirts: "We could argue that the cause of the head injury was concrete, the red shirts, the absence of a helmet, or the truck—but we don't. The impact of the truck is the sine qua non , the cause. The others are influential positive or negative factors or correlations with no influence at all, as in the case of the red shirts." "Of course there are diseases where there is true multifactorial [causation]," Gallo later commented, reflecting on the etiology of some types of cancer. But "HIV causes AIDS, nothing else: you take it away, [AIDS] goes away."
Gallo's book did not dispute the possibility of contributing causes—indeed, over the past few years, he had been proposing that a virus called HHV-6 (human herpes virus, number six) might speed up the process by which HIV destroyed T cells. But HIV could also do its work without HHV-6, while HHV-6 alone did not cause AIDS. HIV, in other words, was both a necessary and sufficient cause. Montagnier,
by contrast, was now proposing that a mycoplasma might be a second necessary cause along with HIV—a claim that Gallo found "astonishing." Montagnier's cofactor theory provided "added longevity to confused and confusing … arguments that HIV is not the primary cause of AIDS," Gallo complained. What particularly irked him was that Montagnier had thereby "lent some support to Duesberg (who, interestingly enough, dismissed Montagnier's idea)."
Gallo could hardly deny that Montagnier had impressive credentials for commenting on questions of medical science. But he was quick to observe that "the vast majority of people who have raised, re-raised, and re-re-raised objections to the conclusion of an HIV cause of AIDS"—here Gallo names Jad Adams, Katie Leishman, Anthony Liversidge, and Chuck Ortleb—"seem to have little or even no experience in science or medicine." What of Duesberg? Gallo acknowledged his colleague's indisputable scientific accomplishments, but stressed that they might not have prepared him to comment credibly on AIDS: "He made very significant contributions to our understanding of the molecular biology of animal (especially chicken) retroviruses many years ago and is a member of the National Academy of Sciences. On the other hand, he is not an epidemiologist, a physician, or a public health official. More important, to my knowledge Duesberg has never worked on any naturally occurring disease of animals or on any disease of humans, including AIDS. Nor, I believe, has he ever worked with HIV."
During the 1989–1991 period, Duesberg also continued to receive publicity in the mass media, including a long and generally sympathetic feature article by Garry Abrams in the Los Angeles Times that asked whether the scientist was "Hero or Heretic." Abrams noted that Duesberg was shocked to learn in fall 1990 that the NIH had declined to renew his five hundred thousand-dollar-a-year Outstanding Investigator Grant. While renewal of such grants is far from automatic, the review committee had written that Duesberg had become "less productive, perhaps reflecting a dilution of his efforts with non-scientific issues." This was a serious blow to Duesberg, and Abrams implied that it was direct punishment for heresy, with the phrase "non-scientific issues" serving as a euphemism for Duesberg's campaign against the orthodox position on AIDS.
One symptom of the thickening of debate was that the media began covering the media coverage. USA Today ran an article on Spin magazine, "the only general interest publication pushing [Duesberg's] theory."
Charles Trueheart reported on the Policy Review debate for the Washington Post , suggesting that the authors' emphasis on the role of personal behavior in the cause of AIDS "may explain why their article appears in this conservative journal."Lies of Our Times , an alternative magazine dedicated to policing the writings of the New York Times , complained that the newspaper had never mentioned Duesberg since Philip Boffey's original article in 1988, and it claimed that "the silence of the Times kept Duesberg out of the major media for three years."
Duesberg also was promoted in places like the New York Native by authors like Lauritsen. Elsewhere in the gay press, the causation controversy was a marginal issue but one that provoked periodic heated exchanges. Writing in the Bay Area Reporter , a San Francisco gay newspaper, columnist and AIDS activist Michael Botkin described the "peculiar revival of interest" in Duesberg's theories. Duesberg "continues to be shunned by virtually all serious AIDS activists," wrote Botkin, "but has sparked some interest from heterosexual, HIV-negative, radical-posing journalists." But while some commentators worried about the consequences of knee-jerk anti-expertism, others expressed the opposite concern—that gays were inexplicably naïve and were following the medical establishment like placid sheep. In a discussion of Duesberg's arguments and Montagnier's "startling admission," Ralph Garrett wrote to the San Diego Gay Times: "In the face of such a scandal, among the questions we in the gay community should be asking ourselves is how could we have credulously surrendered our lives and deferred our better judgement to an authority which has proved to be just as corruptible as any other? … What madness could have come over us?"
From Outside to Inside and Back Again
Conventional views of science presume a top-down model of knowledge dissemination. True ideas originate within a select community of educated specialists; from there, they percolate "downward"; eventually, in watered-down or distorted form, they penetrate the consciousness of the masses. But as Stephen Hilgartner has argued, this model fails to capture the ways in which "popularized knowledge feeds back into the research process." Duesberg's views on AIDS are an interesting example. Early in the epidemic, ideas about
"immune overload" diffused from researchers to doctors and patients and were taken up by lay theorists such as Callen and Lauritsen. Many of these same ideas then reemerged in the scientific articles of Duesberg, who cited the lay publications in his footnotes and thanked their authors in his acknowledgments. As Hilgartner noted, "when one looks carefully for the precise location of the boundary between genuine scientific knowledge and popularized representations, one runs into trouble. …"
There is still another sense in which the pursuit of scientific credibility by Duesberg reveals the considerable permeability of boundaries between the "inside" and the "outside" of science in the case of AIDS. On one hand, Duesberg's success in promoting his views depended heavily on his status as an "insider." As of 1986, dissenting voices on the causation of AIDS were marginalized, and they might have remained so had someone with the scientific credibility of Peter Duesberg not entered the debate. On the other hand, Duesberg's capacity to sustain his critique then depended heavily on support from "outside." His article in Cancer Research might have gathered dust on library shelves, if not for the active promotion of his views by a group of lay supporters who succeeded in pushing the controversy into the mass media. This publicity led to Duesberg's presentation of his arguments in official forums, such as the AmFAR conference, Science , and PNAS . By extending his credibility from one arena to another—using his scientific credentials to buy him popular support, then using the popular support to push for recognition by his colleagues—Duesberg gained staying power. The next chapter describes how Duesberg sought to continue his battle and how the "AIDS establishment" responded.