WILLIAM KAPLA, M.D.
LIFE AND DEATH IN SAN FRANCISCO
San Francisco, California
Bill Kapla was a medical pioneer when he opened his office in San Francisco's Castro district in 1977 specializing in gay medicine. His predominantly male, homosexual patient population was troubled mostly by eminently treatable problems such as sexually transmitted diseases and hepatitis. As it turned out, he was at ground zero for the oncoming AIDS epidemic, and his doctoring was soon consumed by the care of the critically ill and the dying. Working with patients, public health officials, students, and researchers, Kapla has practiced his way through the epidemic, losing his lover as well as hundreds of patients and friends to the disease. Recalling these years, Kapla sits at a handsome mahogany desk amid statues, artwork, and neat piles of patient records and medical journals. Behind him is a bookcase containing Grant's Atlas of Anatomy, Osler's Principles of Internal Medicine, and the Physician's Desk Reference as well as an open case displaying a set of turn-of-the-century surgical instruments belonging to a long-deceased Colorado general practitioner. Kapla has a well-developed sense of history. He is an articulate, tidy man with a blond mustache who speaks with modesty about his accomplishments.
I FIRST BEGAN TO REALIZE I was gay when I was twelve or thirteen years old and I discovered that I was attracted to other boys. That made for a huge struggle within me. Could I really be bad, evil, sinful, perverted? I denied my instincts, and I fought to be “normal.” Being gay didn't fit with what I was being taught either by society or the church. How could God make such a despicable person as me when he was such an all-loving, omnipotent entity? I had no idea then that being gay would provide the overriding definition of my personal life as well, ultimately, of my professional life.
I was a good midwestern boy from a very modest background, born in Duluth, Minnesota, in March 1943. My father was an automobile mechanic who later worked overseeing quality control at construction projects. My mother worked in a grocery store checkout line. My parents were very loving, and I'm sure their goal in life was to raise their two sons as successfully as they could. Our family was Lutheran. We went to church and Sunday school regularly, and I said my prayers every night until, my God, I must have been in my second year in college.
We moved to a suburb of Denver when I was five or six, which is basically where I was reared and educated. The move from Minnesota to Colorado was very exciting. I loved cowboys and Indians, and here we were moving out West where the real Indians lived. My father used to rent a horse for me and walk alongside when I was too small to ride on my own. Then I began to ride seriously on my own, and to this day riding is my great passion.
My first recollection of an interest in medicine dates from when I was about eight years old. My mother, brother, and I were playing a board game, and I asked my mother what she would have chosen if she could have married anyone. She said, “Oh, sweetheart, every young girl wants to marry a doctor.” From that point on, I planned on medical school. By junior high, whenever I was asked, “What are you going to be?” the answer was always, “I'm going to be a doctor.” All my courses from high school on were directed toward premed.
I went to college at the University of Colorado, a gorgeous campus in Boulder with beautiful flagstone buildings. My years there were among the most positive of my life. I worked very hard, enjoyed the school, earned a B.A. in psychology, and was accepted at the University
At the same time, it was a tremendous struggle. I felt extreme isolation and fear that something would happen to me physically. Disease was not the issue then, it was physical harm. To this day, when a gay man of my generation walks along the street, all he needs to hear is “Hey, faggot,” somewhere in the background, and he'll think, “Oh, dear, my time to die!” Straight people may not be aware of it, but queers still get bashed for the sport of it. So growing up in the 1950s and 60s was terrifying.
I was dealing with these issues with the help of a counselor in college. Then, on the first day of medical school, we were all in the auditorium being asked to sign a bunch of papers, and one paper came by that was an attestation to “moral character.” It asked if we were free of any character disorders, and said that any knowledge to the contrary would be grounds for immediate expulsion. Well, I knew what they meant by a character disorder, and I said to myself, “Oh, my God. Sign that puppy and move it along.” That was the kind of anxiety that was ever present in medical school. In the second year of medical school, the top student in the class was gay. His mother and father knew it and were promising him a Corvette if he changed his sexuality. The stress of being gay led him to commit suicide in the fraternity house. The school was in an uproar; no one could understand why he had killed himself. I knew. So I went to the dean of students wanting to inform him but not to incriminate myself, and he was actually understanding and sympathetic. I told him about the stresses on gay students and reminded him about the “moral character” paper we had had to sign the first day. He seemed understanding, and there were no repercussions from our talk. I felt that maybe the conversation had accomplished something.
Dating was also stressful. In the second year of medical school, I was going out with a nursing student for the sake of having a girlfriend, and we tried having sex. It was dark and it was a struggle, an absolute struggle, but I finally had an orgasm in my clothes on the floor of her apartment. When it was all over, I got up, said I had to go, and walked home. Then I got in my car, went down to a gay bar in Denver, and went home with some nice guy. Then and there I decided that I wasn't going to play
My next crisis came in the fourth year, on a psychiatric rotation. A hospitalized psychiatric patient recognized me from a gay bar and told his attending psychiatrist that the medical student was a faggot. I was called in to the attending's office and told, “Well, this is pretty serious. We're going to have to take you off the rotation and tell the other students why this is happening.” First I denied it. Then I said, “Well, there was a time when I probably was considering it, but I'm going with a nursing student.” I still had contact with Nancy, thank God, so I could use her as an alibi. Eventually the attending physician decided that his response had been too harsh and that he would treat the issue as a problem of the patient. I think his dilemma then (it was the mid sixties) was, “Is this student gay and, if so, what are our procedures for dealing with him?” But since I denied it, it let him off the hook. Had I admitted being gay, I'm not sure what would have happened. My fear was that it would have meant expulsion. The incident left me panicky—I was within six months of becoming a doctor, and I thought I was going to lose it all. I went to talk to a psychiatrist friend on the faculty who brought me back down to earth. He just said, “Calm down, don't do anything, don't say anything, and don't admit to anything. Everything will be all right.” And in fact, it was. I graduated and went on through.
In 1969, I moved to San Francisco to start residency training in internal medicine at Presbyterian Hospital. Originally I'd planned to go east for my residency, since I'd spent all of my life west of the Mississippi. But a girlfriend pushed me to consider San Francisco. She claimed that it was a wonderful city, but my impression at the time was that it was a city full of kooks. In the third year of medical school, a friend and I took a trip to California with the idea of looking at residency programs. We arrived in San Francisco for an interview, stayed at the YMCA, which was a notorious gay hangout, and we just went crazy. We spent the entire week in San Francisco, never going on to Los Angeles, because we loved the city so much. When I applied for internships, all of them were within a hundred miles of San Francisco, and I was matched with Presbyterian.
After two years of residency, I joined the Navy. It was 1971, the war in Vietnam was raging, and all doctors had to serve in the military. I chose the Navy because, in my mind, it had more gay people than any other service. I did worry that I'd be shipped to Vietnam and die, but instead I spent six months in Pensacola, Florida, being trained as a flight surgeon,
The Marines and the Marine Corps were wonderful. The image of the Marines appealed to my own personal values and to my sexual fantasies. Presumptions aside, if you are a neat, clean, squaredaway person, they'll ask you to wear their uniform. Well, I wore a Marine Corps uniform the entire time I was in the service. I'm adaptable and try to be an engaging person, so I had no problem with the military. It was easier for me because I knew I wasn't going to stay there. I like orderliness well enough, but it was still hard. I knew that I couldn't stay in the military twenty years and be gay—although, to my great surprise, I met a lot of gay people and realized that the Marine Corps attracted many, many gay men. Of course the word “men” wasn't quite right since many of the Marines were actually still adolescent boys with questions about their sexuality. The camaraderie and all the buddy business appealed to the homosexual tendencies in many young men. Unfortunately the Marines were also viciously brutal if they caught a gay guy in the Corps; they would humiliate him and destroy his career. Homosexuality exists in the Marine Corps, but it's dealt with harshly when it's discovered.
I enjoyed my time in the military because, first, I wasn't going to be there forever and, second, I was always a doctor first and a military officer second. I had tremendous rapport with the troops and the officers. People knew I wasn't a “lifer,” so they could come to me if they had problems. Within the underground it was known that I was gay, so that gay troops tended to come to me when there was a problem or issue.
I spent six months aboard a helicopter aircraft carrier in the Mediterranean. People got very gay aboard a ship. In the ship's setting, where there's no other outlet, sexual contact with a man wasn't viewed as badly as it was off the ship, when the standard roles reassert themselves again. I think that we probably respond to each other first as human beings, irrespective of gender, on a big bell-shaped curve. There are probably a few pure homosexuals among us, a few pure heterosexuals, and most of us are bisexual. When you add the influence of society, history, and religion, it skews that curve markedly toward heterosexuality. It's interesting to note that 25 percent of gay men have children and that many men “come out” only after a marriage. On board a ship, you could see that curve move back toward the middle.
I got out of the Marines without destroying the moral fiber and character of the military and headed back to San Francisco, where I worked as an ER doctor for four years, taking lots of side courses. I found that
During my four years working in the ER, many friends had wanted me to care for them, but the only thing I could do was to bring them through the emergency room and deal with them there. In the process, I was actually creating a very nice gay practice. It finally reached a critical mass, and psychologically I was ready to really deal with people that I liked. So in 1978 I started a primary care practice and forthrightly called it a gay practice in the Nob Hill neighborhood near St. Francis Hospital. I immediately became one of the few doctors in the city specializing in gay health. Herb Caen, the famous columnist for the San Francisco Chronicle, picked up on it immediately. His comment in the paper on gay medicine was that, “I thought you had to be sad, hurt, or in pain to go to the doctor, and here you can be gay and go to the doctor.”
The practice was probably 90 percent gay men and 10 percent lesbians. The patients loved it because, in general, medicine had had no time for gay and lesbian patients. Their sexual preference was seen as a disease itself. Doctors wanted to send homosexual patients for shock therapy. For the most part gay patients had to keep that aspect of themselves secret from the medical profession. In my practice I saw the whole gamut of health problems that affect twenty- to forty-year-olds. On top of that, I saw a horrendous incidence of sexually transmitted disease. This was the sexual free-for-all time when the gay male was becoming a person unto himself, with a new attitude: “No one's going to tell me what to do; I'm going to have sex with whomever, whenever, wherever, I want to.” So I dealt with the STDs quietly. I also became the community's expert on ambulatory proctology because no proctologist wanted to deal with a faggot and his problems.
I reported the STDs to the Health Department, of course. They were obviously concerned about the STD rate, and a wonderful assistant director of the Health Department named Selma Dritz reached out in a motherly way to the gay community. She wanted to know why there were so many cases of parasites in San Francisco, and she thought that maybe it was originating in the gay community. So a rapport was established, and we fastidiously reported all of the odd parasites we discovered to Selma. She started characterizing enteric parasites on a public health basis and producing papers and epidemiological studies. The rapport we
The practice was successful. I didn't know much about how to run a business, but it all seemed to work out. I was all alone until 1984, when I moved to Davies Medical Center in the heart of the Castro, ground zero of the gay community in the world, and two of us joined together to form one practice. I enjoyed being on the crest of the wave of gay issues and gay medicine. I became an expert in caring for the gay patient and was asked to give talks on the subject to interns and residents and medical societies. It became steadily more topical because physicians began to ask, “Oh, my God, you mean I've got faggots in my practice?” And my answer was, “You'd better believe you do—now, here's the way to deal with it.” So that was fun.
Around the same time the gay physicians in San Francisco got together to create a gay physicians' support group, the first in the country. These groups now exist in other major areas, and there's a national organization. We couldn't use the name “gay” or anything like it so, to this day, it's called Bay Area Physicians for Human Rights. The fear was always state reprisals—that the medical board of California would take our licenses away. The medical society of the city of San Francisco would not even allow the gay physicians' association to meet in its building until 1980; they were not going to let faggot doctors in the building. The attitude of organized medicine has been conservative, prejudicial, and slow to change. The American Psychological Association listed homosexuality as a disease until 1974. The following year the AMA finally agreed that homosexuality was not a disease category. The AIDS epidemic has helped a great deal in sensitizing people to the rights of gays.
As soon as I became board-certified in family medicine I was appointed to the clinical faculty at the University of California at San Francisco Medical School. Being gay was not an issue there. At first, gay students heard about my practice through the underground, and started taking electives with me. The rotation became so popular that we started getting straight students as well. I do feel a special obligation, however, to help gay students. It's important to show them a role model that says, “Hey, you can be as gay as you want to and still be successful.”
After the gay physicians got permission to go into the medical society's building, we held a continuing medical education course there on gay medicine. No one else was going to teach us, so we made our own course. In August 1981, Dr. Friedman Keene from New York City came to San Francisco to present a talk on a strange cancer—Kaposi's sarcoma—that he
We had no name for it. It was just a disease complex that was happening—and it was happening in homosexuals. A few bad apples, but not us. Then in 1982 one of our physicians developed a Kaposi's lesion in the back of his throat, and he was dead in two years. In terms of my own practice, it was unbelievable. I remember a horrifying case. I had to tell a nice young man I had taken care of, maybe twenty-three or twenty-four, that his HIV test result was positive. He seemed devastated, but after we talked about it he seemed okay. The following morning I got a call from the coroner: “Could you come down, Dr. Kapla, and identify a body that we cut from a tree in Golden Gate Park?” I couldn't do a thing about it. Some of the finest, most talented, educated, successful people were dying—and no one cared. When you're seventy or eighty, with diabetes and heart failure, and you die, everybody says, “Oh God, wasn't it a blessing.” If you're thirty-two and die, they say, “Good, he was a faggot. … It was God's revenge. … It was deserved.”
Early on, we started to have struggles with bathhouses here in San Francisco. Bathhouses were viewed as the bed of this disease, so there was a movement to close them. But we couldn't just close our sanctuaries, our palaces. The debate was emotional, passionate, vociferous—it was terrible. There was a sense of entitlement: “You can't tell us what to do and put moral restrictions on us.” We knew that when a guy checked into a bathhouse, he got a towel and key, put his clothes into a locker, and then went around and did whatever he wanted to with consenting males. We knew from exit surveys that someone who went to a bathhouse had an orgasm on average two and a half times each trip. Epidemiologically, he came in contact with about twenty people for each orgasm. So he essentially had sex with fifty people each visit. We have on record people with three and four thousand one-on-one contacts in the early days of the epidemic. This became the staggering geometric progression of the active gay male in San Francisco in the seventies. And no one wanted to stop.
In retrospect, it's easy to see how AIDS just exploded in the gay community.
Clinically there were slow but important steps in dealing with AIDS, and by 1984 we were able to test for the disease. But testing could lead to a loss of job and health insurance and make a bad situation terrible. The advent of anonymous testing was a godsend, because we could test people without destroying their lives. But we didn't really do a lot of screening; we were making most of the diagnoses when people walked in manifesting the disease. Now, in retrospect, from hepatitis studies that were underway through the 1970s, we know that as early as 1978 5 percent of gay men in San Francisco were HIV-positive. By 1980 it had reached a critical mass of 20 percent, and from that point on it exploded. It stayed steady for a long time at about 70 percent of the gay men in the city, but that generation is now dying off from AIDS.
Our safe-sex education efforts since then have been so successful that we have now wiped out over 90 percent of STDs in the gay community. It was astounding that sexual behavior could be changed to such a dramatic degree after such uncontrollable activity. If you take the gay white population alone, new cases of AIDS have dropped to almost zero in the last three or four years. Now the great concern is reaching subgroups like Hispanics, blacks, and youth. That's probably the most difficult problem we have—how to reach gay youth. They've grown up in the era of safe sex, and their guard is down. You can't get into the schools very easily to talk about sex, and now the religious folks are saying, “You can't encourage them to have sex. Tell them no.” I don't care what you tell them, that method is not working. The religious types just can't deal with giving a kid a condom. They see it as encouraging, giving them implicit permission to have sex. But if I don't give them the condom, they're still going to do it anyway. Kids view AIDS as the old man's disease, the thirty-and forty-year-old's disease. They see themselves as omnipotent, invulnerable. It's very hard to reach them.
In 1985 the first drug against HIV—AZT—came on to the market. People struggled to take the drug at virtually three times the dose we give
My practice—like many HIV/AIDS practices—has become more out-patient-oriented, probably a little easier, although still very demanding because these patients continue to be very complex and time-consuming. They're a lot more stable, so there's less change from visit to visit as compared to times past. In addition, unfortunately, we still are seeing people seroconvert, so we're still having to deal with new patients, some of whom suspect they're HIV-positive and some who don't. For people who don't suspect, the diagnosis remains as devastating as ever, requiring a great deal of support from me.
Gay physicians became medicine's experts at dealing with AIDS. We were called upon incessantly for help, guidance, and education, because we were already running annual updates and education courses for ourselves. It just got larger and larger. We were our own educators and the educators of others.
Since the beginning of the epidemic, all the diseases occurring in association with AIDS were known diseases, but they just happened to be occurring in Godawful unexpected situations and combinations. Even though some of them were unusual and difficult to treat, at least we knew what we had to deal with—pneumocystis, fungal diseases, lymphomas, and the like. AIDS really needs to be treated by a primary care physician because so many organ systems and medications are involved. The patient needs a single doctor with an overview to guide him through the incredible quagmire of care. Most care today is managed on an outpatient basis, and primary care for the person with AIDS is often a team affair that includes the patient. Doctors don't usually deal with patients who know about their diseases, let alone patients that arrive at the office
We have become compassionate experts in death and dying. Medicine has always dealt with death and dying—oncologists with cancer patients, for instance, and internists with the elderly. But what do you do with a strapping thirty-two-year-old male who's dying on you? What kind of effort do you make medically? Do you give him every single thing medicine has to offer and make him suffer terribly in the process? Fortunately, we have gotten better at dealing with death, and we now have some very good legal instruments with which to modify the allout approach that can be so punishing. We learned the art of how to care for dying patients and make them comfortable. We tell them to let us know when they have had it because we won't do anything to prolong the suffering. We let Mother Nature take her course. That has now become the standard of care, reflected in our directives.
In my practice today, I continue to work with an associate. We see about 1,200 to 1,500 people, some 85 percent of them gay, and some 90 percent of those are male and 60 percent are HIV-positive. We're on the Davies campus of California Pacific Medical Center, in the Castro area of the city. Since the gay community moved into this area over the past three decades or so, we've had to address their issues and needs, and this is now the premier private AIDS hospital in San Francisco. When AZT first came out in the early 1980s, this medical center was prescribing 10 percent of Burroughs Wellcome's entire production of the drug. There was a time when there were about twenty primary care practices that served the gay community of San Francisco, and fourteen of them right here at Davies. Gay patients are a little more spread out now because there are more physicians who will treat them, and insurance company reassignments have distributed the community a bit farther into other medical practices. The white gay community is a very successful segment of the San Francisco society, both professionally and financially, and therefore they usually have great health care benefits. The Hispanic and black gay populations are not as financially successful overall, they don't have the same benefits, and they're much harder to reach with educational programs.
In recent years it has become increasingly difficult to practice medicine
In 1979, I met a wonderful man, an architect named Jack. We lived together in a beautiful home overlooking the city. In 1984, a good friend who was living with us developed AIDS, and that's when Jack and I decided to get tested. He was positive and I was negative, an agonizing situation. Although initially I thought nothing would actually happen to him, in 1987 Jack developed AIDS and started on a very difficult, three-year downhill course ending in his death in 1990. I spent ten years without a partner, and that was very difficult. Physical beauty is highly prized in the gay community. Gyms are filled with gay men taking care of themselves and working to stay young. But because of this, a gay man in his forties and fifties goes through a lot of adjustment because he's no longer as physically desirable. Often it is difficult to socialize and to find another partner as one ages. I'm still hoping to live to be 101, and I'd love to be able to celebrate a thirty-year wedding anniversary. Happily, in August of 1999 I met a wonderfully loyal and devoted man named Mark and we're off and running on our thirty years.
My gayness was very hard for my parents in the beginning, but the last fifteen or more years have been wonderful. They don't talk about my sexual preference to their friends and family, but I think it's generally understood that I am gay. They adored Jack from the start, and that helps me to know that they are fully accepting of me. My brother has a hard time with my being gay, as does his wife, and I'm not as close to them as I would like to be. They have four wonderful, successful children that I've always felt were kind of kept distant from their funny uncle in San Francisco. I have become involved in an exciting program here in the city involving mentoring of gay youth. I think the youth are our most valuable commodity in this country, and I'll probably devote the rest of my life to making growing up gay easier than I had it.
Today you can hardly find anybody in society who hasn't been touched by AIDS. Awful and tragic as it has been, the epidemic has done a great deal to educate the community in general about sexual preference, sexuality, and goodness knows, HIV disease. There's far more acceptance of gays now than there was twenty-five years ago. For someone my age, I'm just astounded by the changes. I thought I would live to see the day that maybe it was okay to be gay and yet, now, we've got such incredible political power here in San Francisco and elsewhere. And I'm blown away by the talk about gay marriage—I just never expected it. Changes are coming so fast it's amazing. I guess that's part of getting old. Life's going so fast; it's going to be over here soon.
