GUEST: Dr. Mathilde Krim
I’m Richard Heffner, your host on THE OPEN MIND. When the San Francisco Chronicle published a selection of its own 1984 coverage of AIDS, it called it “The Year of the Plague.” And it’s clear that the northern California bay area is intensely aware of Acquired Immune Deficiency Syndrome. But other selections of our country are also altered to this modern scourge. First recognized as a disease in 1981, and its epidemic qualities command the medical community’s most profound concern. As it should ours.
So that our guest today is Dr. Mathilde Krim, the distinguished researcher at the Memorial Sloan Kettering Cancer Center who heads the AIDS Medical Foundation and who recently was quoted not only as characterizing the AIDS situation as “very worrisome,” but also as thinking that the American people have been reassured too much about the disease.
Dr. Krim, thank you for joining me today. And I guess the first question I want to ask is: Why we have been reassured quite so much?
KRIM: Because we had a bad experience. I think it was two years ago, now. When the newspapers suddenly carried stories about AIDS and the horrors of the disease, the fact that it was contagious, without explaining sufficiently that it is not contagious under ordinary life circumstances. It takes very intimate relationships for this disease to be caught by one person from somebody else. So the public was ignorant, and was surprised by the frightening new and the reaction was really dreadful. You may remember overnight we had policemen who were concerned, people in funeral parlors refused to accept bodies of AIDS patients who had died, paramedics refused to take care of AIDS patients, and so forth.
So, I suppose our institution became scared. Government agencies and the word was out to try to reassure the public. Unfortunately, it was too much so. And particularly the implication that this was a disease of only certain people was wrong. It is not. Diseases don’t discriminate. Diseases start in certain groups but they usually don’t stay there. And that is what’s happening with AIDS now.
HEFFNER: How concerned should we be?
KRIM: We should be extremely concerned. And yesterday I attended a meeting organized by the Food and Drug Administration with representatives of our public health service. These are all doctors, people who are used to deal with public health emergencies and catastrophes and it was clear that they’re extremely concerned. Mainly because we know so little about this disease.
HEFFNER: Not because of its contagious qualities?
KRIM: This too, but the fact that we don’t know really what…See, the disease, we believe, now is caused by a virus. That not all people are infected with this virus develop the disease. There must be other factors that make somebody go on to actually developing the deadly disease. We don’t know what these factors are or whether there are any. Maybe there are none. Maybe everybody who is infected will become sick. But that would be extraordinary, because it’s usually not the case. We don’t know any disease where this is the case. Usually some people among all the people infected, some go on developing the disease. We don’t know who they are. We can’t identify them as being at higher risk than others.
It is also a contagious disease. It is transmitted sexually, but it is transmitted to everybody potentially. Now, and we have no treatment for it either. And it is not even a disease, it is a syndrome. The disease is the underlining condition upon which other diseases are grafted, so to speak. And the patients with AIDS have an immune system that doesn’t function at all, and they become extremely susceptible to all sorts of infections and cancers, several types of cancers.
So that the treatments we can apply to this treatment for those added diseases. And the treatment, those treatments are not effective I many cases.
HEFFNER: But, you know…
KRIM: And we cannot cure, cannot treat the underlying defect.
HEFFNER: But you know, we began by asking you, I began by asking you why we had been reassured too much. And you say because the initial description of the disease and of the spread had been quite so frightening and had been identified with socially discriminating notions.
HEFFNER: But, what now? You say we should be concerned. Should we be frightened? Which is another word, and it’s a very fair one too.
KRIM: Yeah, we should be, but not…You know, fright is not a constructive attitude. I think we should be concerned and we should be determined to do something about it. And there are a number of things that could be done.
Number one could be a broad public education campaign, which has never been carried out.
You see, this disease is now breaking out of the original at-risk groups. It started in the male homosexual community. It is now found in female prostitutes, in I.V. drug abusers, and even at a higher rate than in the gay community. It is spreading through the sex partners of all these groups. And I.V. drug abusers are not homosexuals, they are heterosexuals, most of the, and they have sex partners. It’s spreading to these partners. These partners are often, are often people who are not informed at all. They are not even aware that they are taking a chance. They have to be warned, and this has not been done yet.
KRIM: For fear of creating a panic, I think.
HEFFNER: Now, is that a, an official government position…
KRIM: I cannot say so…
HEFFNER: Which may not be announced?
KRIM: …it has not…No. It has never been announced…
HEFFNER: No, no, no, no. But is it, in your estimation an official posture? It’s such a frightening thing we don’t want panic, and let us not…
KRIM: It may have been no so much official as shared wishful thinking. People may have believed that this is legal way or that it may be limited to certain groups and never move out. Also, the rate of the epidemic, of the spread of the epidemic was hoped, in 1983 there was a little plateau, and then certain officials said, “The spread is plateauing.” Well, it was not. They had changed the reporting system so there was a delay, but it appeared as a plateau. And, you know, we have, we came through a rude awakening. In 1984, we know now that the total number of new cases doubled. If we ahd 4,000 patients with diagnosed AIDS at the end of ’83, we had 8,000 at the end of ’84. We have now in the six and 7,000.
HEFFNER: And I wonder whether the…
KRIM: For ’85 alone.
HEFFNER: Is the rate of increase increasing?
KRIM: No, it’s not increasing, it seems to be stable, but it’s doubling every 10 to 11 months, which is really frightening. And since we don’t have a treatment and we don’t have a method of prevention, not even through public education, as of today. So we can expect, and in fact officials of, the doctors of the Center for Disease Control say so openly. They know that next year we are going to have 16,000 new cases and two years from now 32,0000 new cases.
HEFFNER: And the result of that is what in terms of governmental policy, governmental attitude?
KRIM: Unfortunately, very little. And I personally feel the government is really—maybe “betrayed the public” is a very strong word—but misled the public and endangered the public. You know, when this disease came on the scene in 1981, and in 1982 we saw a doubling of the cases, and in t 1983 we saw a new doubling, we should have not only started on a public education campaign but made an extraordinary effort in research. Research efforts were made in certain areas. As you know, it has been quite an accomplishments to isolte, for example, a virus that we now know is etiologically involved, is the causative agent, either the causative agent or a very important causative agent. But efforst in the area of treatment, for example have been minimal. There are a number of drugs that we know could perhaps suppress, we hope, we know, we have indications from studies in animals, could suppress the multiplication of this virus, and these have not been tried. Virtually not. A number of them have not been tried at all; one or two have been tried on a very limited scale and probably in the wrong patients. We always try clinical, start clinical trials in patients who are not too sick. We should start with patients with very early disease or perhaps immediately after infection to have a better chance.
HEFFNER: Dr. Krim, I always make the automatic assumption, being a good American, that scientists in particular do things the right way. Why is this being done the wrong way.
KRIM: Scientists need the means to do things the right way.
HEFFNER: Just a matter of funds?
KRIM: There are ma…Yes. I think so. I think there are problems that need to be monies thrown at them, because we have the talent in this country. You know, I have an enormous confidence in the power of science and of biology in particular. We have made fantastic strides over the last ten years on our ability to analyze biological problems, to produce new methods of treatment, to produce special proteins to use as vaccines, for example, which is one thing we should be doing for this disease and we’re trying to do, but perhaps also not energetically enough.
I believe in the power of science, but scientists, you know, cannot do things by themselves. They need to be organized, they need to be given the means, and, and the support to do their work.
HEFFNER: You have been so much identified with research in terms of cancer.
HEFFNER: Does our success or lack of success in that area make you more sanguine, make you more hopeful in terms of AIDS or to the contrary.
KRIM: No, I think it makes me more hopeful. You know, in the field of cancer, the field of cancer is one of those fields where we have made tremendous strides. I am not talking about treatment. Treatment is always lagging. But in terms of understanding the basic cellular mechanisms that lead to cancer, we have made tremendous strides, And there, you know, the time was needed, because cancer is such a different disease from anything else. And we needed to understand the molecular biology of the genetic material to understand what causes cancer. I think within the ten years we’re going to develop panels also for treatment. I’m convinced. I think our children, the generation of our children, will not die from cancer, or rarely.
HEFFNER: Are you suggesting, though, that AIDS is not similarly complicated and…
HEFFNER: …won’t take as long a time or wouldn’t take as long a time…
KRIM: No, the understanding of AIDS, you see, has benefited from what we know about cancer. AIDS is, is caused by a virus that belongs to a family that is quite unusual among viruses. AIDS has been difficult to understand for quite awhile before this virus was isolated because this virus behaves in a way which is quite unlike other viruses such as hepatitis or polio virus or influenza virus. We had, we still have to, to a large extent, understand how this particular virus behaves in the human species. Such viruses were known in animals, but not in make before. This is one reason why it is so difficult to predict what will happen to a patient infected with the virus, because we, we have no comparison. We can’t make analogies with other viral infections in man.
HEFFNER: But it seems…
KRIM: But I think we’ll get there, and, and the advances we made in cancer will help with understanding AIDS.
HEFFNER: It seemed to me that you were saying for a moment that the problem was a public health problem, and then it seemed to me you were saying it was a research or scientific problem.
KRIM: AIDS isn’t any problems, it’s a problem in each of these areas. It’s a public health problem because it endangers a large number of people, it requires public health measures to, to, to slow down the spread of the disease. To teach people how to protect their own life and that of others to, to deal with patients with AIDS. We are going to have many around. We’d better learn how to treat them. We must, first of all, understand that the disease is not contagious through just touching hands or kissing somebody or riding a bus with a patient with AIDS. That’s not the way it is transmitted. There is no danger of that, thank God, there is none. So, in the respect it is a public health problem. It’s also a scientific problem, and it’s also a medical problem.
HEFFNER: Do you anticipate that the spread factor will change as a larger and larger percentage of our population is infected by AIDS, that the mechanism of transmission may itself change?
KRIM: No, I hope that by, you know, I hope that over the next few months public education campaigns will be run, and that, quite the contrary, the spread will be slowed because people will know what kind of protections to use to avoid the disease. For example, in the gay community, gay men have significantly changed their behavior that this is already reflected by lesser, for example, lesser incidence of certain sexually-transmitted diseases of others, which is a reflection of the efficacy of changing one’s behavior.
HEFFNER: But that has to do with targeting a particular segment of the population, and you’re suggesting that more and more…
KRIM: Everybody needs…
HEFFNER: …of us to be concerned.
KRIM: Yes. And the gay men, you see, they were educated because they have their self-help groups. There are gay organizations taking care of distributing accurate information and informing people. They have counseling, counseling mechanisms going on. And, they have very much permeated their community with information, but this has not been done on the outside at all.
HEFFNER: Dr. Krim, you’re an educator as well as a researcher. And I don’t expect that you, any more than the others in the medical establishment, at the beginning, would be willing to frighten people. But I wonder what your own estimate is as to our capacity to learn through a public education program about this. We really didn’t learn quickly about cancer and smoking. We didn’t really learn very quickly about, and perhaps have not yet about diet. What potential do you think there is, before we frighten everyone, for learning, for education?
KRIM: Let me be a little frightening, and maybe useful in this case. It’s, it’s different, you know, than smoking and cancer or whatever is the other example that you gave me…
KRIM: Weight, yes. Because people don’t really believe they die of obesity. It’s more for esthetic reasons that they, they go on diets. They don’t take it very seriously, most of them.
HEFFNER: Do you think they believe this?
KRIM: They better. Because, you know, the lifespan after diagnosis of full-blown AIDS as defined by the Center for Disease Control is about two years. And that has to be learned. People have to…You know, it will sink in, I think. There will be enough patients around that’s dying.
HEFFNER: Does the phrase then that the San Francisco Chronicle used, “the year of the plague,” does that seem to you to be not too outlandish? Seriously.
KRIM: I think…
HEFFNER: Don’t be cheerful for the audience.
KRIM: No. No, it’s not outlandish. It is a dreadful situation. However, I think what I, what I don’t like about this title is that “plague” conjures visions of the middle ages and a total impotency of everyone in the face of this disaster. I think we live now in the twentieth century. We are extremely powerful in what we can do when we set our mind to doing it in the scientific area. I think if there was a truly concerted general effort to stop this disease and to learn how to treat it and to learn how to vaccinate against it, in a few years it, won’t be immediately, we could do it. We could get rid of it in the next ten years.
HEFFNER: And what’s your anticipation of what will happen, very seriously?
KRIM: On the basis of past performance, I am pessimistic. For example, the Reagan administration is proposing now to cut biomedical research, including AIDS research.
HEFFNER: And what do you think the result of that will be? Practically, for our audience, the people who are listening…
KRIM: Oh, it will cost lives. Unquestionably. I think thousands of people will die. Perhaps more than thousands if this comes to pass. I think not only should AIDS research not be cut, it should be increased. Considerably increased.
HEFFNER: And the potential for that? From the private community perhaps? I mean, your own foundation is a privately supported one.
KRIM: Yes. Yes. And I Must say we have run into many people who understanding of the gravity of the situation and have been generous. However, we are too small. You know, we are totally inadequate to, in the face of a challenge like this.
HEFFNER: In terms of the concern for an exponential increase six months or ten months after ten months after ten months, is “epidemic” a proper word?
KRIM: Yes. Yes, “epidemic” has, can be defined in two ways, you know, either on the basis of the number of people affected and usually it’s a spreading disease, but affecting a certain size population, I think the number is 200,000, well, there are more than this number of people infected with the…
HEFFNER: As of now?
KRIM: …virus. As of now. Yes.
HEFFNER: Many more. And then…
HEFFNER: What’s the potential for spread there, from those people?
KRIM: Well, if every one of those infected people has a sex partner, and interacts with that person…
HEFFNER: But not a homosexual person.
KRIM: No, heterosexual partner. The infection will spread, you know. And on the basis of past experience, we think now that some 20 percent of everyone who is infected with this virus goes on into developing the, the fatal disease, AIDS.
HEFFNER: Now, you talk about a public education program. What would it consist of? What do you want people to know?
KRIM: They have to know that the diease is spread through sexual contacts with other. That it is spread through transmission of bodily fluids. These can be blood, semen, urine, and saliva, although saliva is low in the list. There is really no evidence, although one can find the virus in saliva, that anyone has contracted the disease through saliva. The virus does not subsist in the air or in water. And apparently one cannot catch the disease by sharing a glass with somebody, or in sharing a bathroom. So that it is a preventable disease, you know. It requires for people to do a certain thing that they must not have done before and maybe it will cause a certain amount of inconvenience and unpleaseantness, but the disease is preventable. And the public has to know that.
HEFFNER: Do you say, “may require people to do what they haven’t done before.”
HEFFNER: Won’t it require them not to do what they have done before?
KRIM: If you want. That’s one way of putting it, yes.
HEFFNER: Well, that has, of course, raises the question that many people, it seems to me, agrees as to whether AIDS, maybe its development, and I gather, certainly, its spread isn’t a function of attitudes toward sexuality initially that are very current, that are very modern, and that perhaps we are paying a price now for different social patterns.
KRIM: Yes, we are. You’re right.
HEFFNER: Can that be reversed? Should it be reversed?
KRIM: It will have to be. It will have to be. We went a little too far in our social revolution. We had, we have to wait a little longer to have the biomedical revolution that goes with it. We are going to have to learn how to protect ourselves against this virus or treat infections by this virus before we can go back to the old patterns of behavior. And it’s not impossible. The male gay community has learned that. They are actually doing it.
HEFFNER: But in terms of what you have said now about the spread in the homosexual community…into the heterosexual community…
HEFFNER: …it may be too late. No?
KRIM: For some of them, certainly, but perhaps not for all of us.
HEFFNER: I don’t understand that. For all of us if this…
KRIM: No, because some of them are infected already.
KRIM: And probably in, you know, in large numbers. In large numbers. I was saying that on the basis of limited surveys done already with a test that is really recently become available, it is estimated that somewhere around half a million people have been infected by this virus already. Ten percent of those are going to develop the disease and die.
HEFFNER: You’re not very happy about the uses that may be made of that test, are you?
KRIM: No, because it is not the best test possible. But the pressure to do something…It is a test that measures the production of antibody against this virus. Now it so happens that this virus is a poor antibody inducer, in that the time that elapses between exposure to the virus and production of measurable levels of antibodies is rather long. It has been estimated at six months. It has been difficult to estimate because in order to estimate this time you must know exactly the date of exposure. But in the case of people who caught the disease because of a blood transfusion, transfusion with contaminated blod, the date of exposure is known, and therefore one knows the length of time.
With the test that measures antibody, if you test somebody with has not yet developed antibody, the person will test negative although he will be infected and infectious, capable of transmitting the infection. This is what I don’t like about this test.
HEFFNER: Dr. Krim, in your experience as a researcher, is there anything comparable to this situation in our times, in this century?
KRIM: Absolutely not. It’s truly the expression “mind boggling” is justified there. There is nothing like it.
HEFFNER: And yet I know you said at the beginning of the program, you said to me before we started you’re a little bit depressed today in terms of what you heard at the conference in Washington.
HEFFNER: Depressed about the educational matter or depressed about the scientific aspect of it?
KRIM: Both. Again, both. Both, I’m depressed because people don’t seem to understand the gravity of the situation. I believe they have not in the past. And the facts are really dismal. You know, we know, I just mentioned that people develop an antibody against this virus. Now, in most cases, in most diseases when you develop an antibody it means that your body fights the infection and many people are in fact protected by the antibody and never develop a full-blown infection and disease. In the case of AIDS the antibody is not neutralizing for the virus. People can have both antibody and infectious virus in their blood. That has implications for the development of a vaccine.
HEFFNER: Positive or negative ones?
KRIM: Negative ones. We are going to have to modify certain proteins of this virus in order to make them immunogenic and are capable of inducing an antibody. And this is very difficult to do. I think we will be able to do, I am confident we will, but it may take years. I twill take a long time.
HEFFNER: In the meantime, just as we come to an end of our program, I wonder if you anticipate panic in the streets.
KRIM: No, not really. I think we’re dealing, but an large with an intelligent public and, you know, the panic of last year over one or two isolated incident was a bit of futility. It was indulging into panicking if you want. I think in front of really serious news the public will respond reasonably.
HEFFNER: Dr. Krim, I hope that you’re correct, and I hope that you will join me maybe a year from now and look at it and be more optimistic.
KRIM: Thank you.
HEFFNER: Thank you so much.
And thanks, too, to you in the audience. I hope you’ll join us again next time here on The Open Mind. Meanwhile, as an old friend used to say, “Good night, and good luck.”