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 ."^[86] 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.^[87]

Duesberg's article was eventually published by PNAS in February 1989,^[88] with a second one to follow two years later^[89] —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."^[90] 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."^[91]

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:^[92] 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.^[93] 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."^[94]

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."^[95]

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.^[96] 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,^[97] 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."^[98]

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.^[99] 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."^[100] 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."^[101] 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."^[102]

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."^[103] 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,^[104] 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. …"^[105] 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."^[106] 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."^[107]

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."^[108]

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,^[109] 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."^[110] 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^[111] 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."^[112]

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."^[113]

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."^[114]

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."^[115]

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.^[116] 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."^[117] 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.^[118]

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."^[119]

Duesberg and Ellison were given the last word, and they had plenty to say.^[120] 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."^[121]

"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.^[122] 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.^[123]

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.^[124] 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.^[125]

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.^[126] 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."^[127] "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."^[128]

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)."^[129]

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."^[130]

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."^[131] 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."^[132]

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."^[133]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."^[134]

Duesberg also was promoted in places like the New York Native by authors like Lauritsen.^[135] 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.^[136] 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?"^[137]

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."^[138] 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.^[139] 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. …"^[140]

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.