GUEST: Dr. Mathilde Krim
I’m Richard Heffner your host on The Open Mind. Our subject today is AIDS and my guest is Dr. Mathilde Krim, the distinguished research scientist who serves as co-chair of the American Foundation for AIDS Research. Now when Dr. Krim sat at this table two years ago, we were characterizing the AIDS situation as very worrisome and wondered whether Americans hadn’t been reassured too much about this new and dreadful disease. But that seems like a blissful eternity ago. Today, no one feels reassured – we’re not worried, we skirt on the edge of panic. Then the San Francisco Chronicle had called 1984 the year of the plague. This year has been far worse and the next is certain to bring even more deaths and social destruction – a plague indeed. Obviously, we must keep our wits about us, particularly in the midst of calamity that will only worsen, that we can deal with only as we apply careful, measured reason to it, and only as we are humane and sympathetic in caring for its victims. The disease is a horror, it will worsen, but it will do so intolerably if we do not research and deal with it in the laboratory and in our medical facilities as wisely as we can. It will destroy too if we panic. What is needed then is social policy that is measured and wise and scientific endeavor that is in fact unstinting, totally without limit, that is as massive as what I want to discuss today with Dr. Krim. Dr. Krim, I’m so pleased that as we taped this program on the 20th of September, there is good news that makes my grim introduction slightly less so, and I wondered if you would tell us what your own reaction to the announcement yesterday about AZT.
Krim: My reaction was a sense of happiness and hope and I’m sure that this was shared by millions of people who are worried about AIDS or who care for people with AIDS.
Heffner: Not hope that we have a cure.
Krim: No, I would not…we don’t like to use the word cure ever, we like to use the word treatment or therapy – and therapy is an effective treatment. We can say that with AZT, this new drug, we have a therapy – we have something that for the first time has demonstrable effect on the underlying cause of AIDS. AIDS is the terminal phase of an infection often acquired years previously, that is relentlessly worsening in people and in the end destroys their immune resistance, their resistance to other diseases and makes them susceptible to developing infections and malignancies – cancers – of which they die. And this last stage of the disease of the infection is called AIDS. Now we have a drug that can obviously…that has prevented people from dying over a period of six months during which they were taking this drug. And in addition to doing that it has enhanced their immunologic responsiveness, their ability to fight off germs, it has improved their appetite and their feeling of well being – from being a very emaciated, very thin and weak and tired, they have become more vigorous. Many of them have left their bed and have been able to go back to an active life. So it is…I don’t often talk about miracles but this comes close to being one.
Heffner: But we have to avail ourselves of miracles. Now do people do that? How do individuals who are concerned about…whether doctors or patients.
Krim: We are presently going through a very difficult and painful period because a number of drugs have been tested are still being tested. This one, really unexpectedly, has been remarkably effective and it is because it has a large amount of specificity. It inhibits the multiplication of the one particular virus that leads to AIDS. It does very little or nothing to human cells. It doesn’t have toxicity, it doesn’t make people sick – within certain doses, of course. And therefore this specificity and its relative lack of toxicity has made it usable very simply and very easily. And almost overnight it could be given a short trail using just a few people at different doses, but it was found that it can be given quite safely. So a first large…larger control trial involving about two hundred patients was done. This is the trial that brought results rather rapidly, in fact, more rapidly than anticipated and the trial was interrupted in the middle because the results were in – the answers were in. and now the company that produces this drug – which started producing it probably in milligram amounts, then in gram amounts, and perhaps in pounds amounts now, to make it available for several hundred patients in clinical terms – now is being told, and will be asked, and it has agreed to try to do so, to make It available almost overnight because the demand will be tremendous. Imagine, to thousands and thousands of people. So it had to specify to whom it can make it available. The company, Burrows Welcome, has supplies for approximately 6,000 patients. This is only half of its patients. It is only 10% of all patients with ARC, which is as lightly earlier stage of the disease, but there is no logical reason why it should not be given to all of them and the patients know it and they are all going to ask for it.
Heffner: Is there any logical reason to assume that the company will not be able to produce it at the level and the quantity that you want?
Krim: No. I think the company is making great efforts, tremendous efforts to upscale production as fast as it can, but these are difficult things to organize. It takes not only the people in the lab, but supplies, logistical problems to be solved – the company does not have in its own facilities, labs and instrumentation capable to produce very large amounts of these drugs. So it is trying to make agreements with other companies, even overseas in Japan and Germany, whoever has the proper capabilities to build up the necessary stock. And they are now talking about producing tons of this next year. So you see, within one year they had to go from grams to tons.
Heffner: You know, I see the smile on your face and I think back to the last time we spoke and how grim the situation was, but…
Krim: It is still grim.
Heffner: That’s what I wanted to ask you about. When…when is…when does the drug become effective? How do we know that this is the time that the drug can become effective in a particular individual?
Krim: It is well known that this drug is very effective, and very specifically so, against the virus called HIV – Human Immunodeficiency Virus. The infection caused by this virus is the one that slowly but surely leads to AIDS or to ARC…let’s say…it is not always deadly – at least after six years it hasn’t killed everybody who has been infected with it, it only killed so far only half or so of the people infected. So that, rationally, logically, anyone infected with this virus should be treated almost immediately. This cannot be done yet because we don’t’ know how long people can take this drug without any side effects because so far the experience with it has only been a few months.
Heffner: But you say that rationally, logically, the time to begin it is as soon as we know.
Krim: Certainly not much earlier than when people have symptoms of AIDS.
Heffner: What do you think the impact of this phenomenon will be upon the willingness, the necessity, and then the social demand that people be tested?
Krim: Tested for anti-bodies to the virus?
Heffner: Tested for the signs of…
Krim: yes, that’s right. I think it will change the need or our conception of need for a test, absolutely. Because one reason to say that testing was…is not necessary, not called for and even risky for social reasons, is that there was no logical reason for the test for a number of reasons, but mainly because it was useless medical information – there was nothing we could do about the infection anyhow. From now on, of course, that changes.
Heffner: And we are going to have a greater social problem then, aren’t we? Wouldn’t you foresee a…
Krim: Perhaps. No, I think the test, even if used, and I advocate its use, but I think it should be done completely voluntarily and it should be at the discretion of any one person – people who want it should have it and I recommend that they do it. But it should never be mandatory.
Heffner: But Dr. Krim, in the past, in the last two years, the argument against a mandatory test…against mandatory testing, one of the arguments is you say yourself is that the knowledge we would have at that point was not susceptible to medical treatment. It might have been a tool by which those who wanted to discriminate against those who were infected could do so…
Krim: …wanted to identify them.
Heffner: Wanted to identify them and then take whatever social action. Now those who press for mandatory testing have something else on their side…
Krim: On their side.
Heffner: Yeah. And how are you going to respond to that?
Krim: Well, they don’t have it yet because, as I said earlier, the drug is not available yet to everybody.
Heffner: But you want them to have it.
Krim: I want the drug available first, yes – to everybody. And then I think people voluntarily will want to know. Most of them are going to ask for the test voluntarily. There may be at first recalcitrants who don’t want to know at all and don’t care. That’s where the proponents of the test will have an argument.
Heffner: That’s what I’d like to get straight in my own mind in terms of the medical information. I gather what we have now is a drug that seems to be quite effective at the early stage, not later when there are subsidiary diseases that take place.
Krim: No, the evidence is that It has been effective even at the very late stages because eh trial conducted up to now was in patients with AIDS…most of them were patients with AIDS. So it is effective there too. But it would probably be more effective in the earlier stages of the disease.
Heffner: Why do you…you’ve expressed your enthusiasm, your optimism – I’d like to get back to the question why you personally would oppose mandatory testing if indeed we can respond now to a test that demonstrates that someone is…has been victimized by AIDS – we now have something…we now have medical treatment to use against it.
Krim: Okay, but why mandatory? You know, the test, if applied in a mandatory fashion, will identify people infected but how do you force people to be treated, to take the pill – if they don’t want to take the pill, you know …the mandatory aspect of both testing and treating is abhorrent to me. I think people will act in the best interest when they know that if they should have such an infection and leave it untreated, it may cost them their lives – I think they would want to be tested and they’d want to know and they’d want to be treated. I prefer to leave it like that.
Heffner: I would bet too that there were those who are going to say that until you can demonstrate with no question whatsoever that this is an absolute cure, that this is simply a device to smoke out those who were and have been unwilling to be tested. Did you say that it’s a moot question that you say almost by definition – people will want to be tested, and they will and you don’t want it to be mandatory.
Heffner: Not even for the sake of a society that…
Krim: No, because I don’t believe you can force people to be treated. When they are informed that the opportunity for treatment exists, and for testing exists, if they still don’t want to e tested, they are not going to take their pills. So what’s the use of identifying them – to lock them up?
Heffner: When we spoke a couple of years ago, you talked about the…the changeability of the structure of this virus, it I remember correctly.
Krim: Yes, yes.
Heffner: And that to you was one of the more threatening…
Krim: …possible problems.
Heffner: What has happened in the last two years to…
Krim: Well, I think the fear that this might be a major problem has decreased. There are preparations of antibodies now that have been demonstrated active against different strains.
Heffner: And no matter how it changes?
Krim: Exact…well, no, not no matter what. Against different strains that have been tested and had genetic variations between them. The natural antibodies seem to be active against different strains. Now, obviously we haven’t tested them all, you know. But that does not seem to be…so far it has not been a major problem.
Heffner: And the question of…of…
Krim: …also, there are certainly, in this virus, part of…factions of the surface protein that remain constant. So if these should be antigenic…immunogenic, capable of eliciting the protective antibody, one vaccine would work against all of the strains.
Heffner: But we had concerned about, when we spoke about this, if I remember correctly again, had been the changing of the modalities of communication – the transmission facilities. You spoke then about certain limited ways in which AIDS could be communicated. Did you change that?
Krim: No. that has remained. We know very well…we are quite sure of what we are talking about now when we say this virus is transmitted in natural conditions, sexually. We know it goes every way possible – between men, between women, from man to woman, from woman to man, and from mother to child in the womb at birth – not from mother to older child – this is only at birth or during pregnancy. We know it is transmitted through blood, through dirty needles. We know that although it has been found in samples of saliva, or I think even tears, it has not been transmitted in this way – in any way that is detectible. We don’t know a single case, although it has been looked at, that were transmitted strictly through saliva or tears. So when we say that contagion is very, very unlikely under conditions of normal, social, casual interactions, we are quite sure of what we’re saying.
Heffner: You are more satisfied with that statement now than you were two years ago.
Krim: Yes of course, because with experience we learn more all the time.
Heffner: do you think we’ve learned that as a people or that we’re still as frightened of the …
Krim: No, there are still people who are very frightened – people who are very ignorant and talk nonsense. I was once in an airplane sitting next to a very distinguished looking gentleman who happened to be a banker and we were talking about AIDS and he said to me that he knows how to protect himself against AIDS. So I said, really, I would be interested in knowing your thought about this. And he said, well, I don’t eat any more in West Hollywood restaurants. We still run into people like this.
Heffner: And the food isn’t so good there any way (chuckle), so I can understand that.
Krim: That’s sure not true – some restaurants are very good in West Hollywood.
Heffner: What is your own feeling about where we are going to go next in this country – if we meet together here two years from now, where do you think we’ll be…this nation will be in terms of AIDS….it’s not just this nation, but the rest of the world.
Krim: You know, what worries me the most right now is that I think definitely – and I’m optimistic really now – we are going to develop treatments and AZT is only the first of a number of drugs that are going to be effective. And I think two years from now we are going to have a treatment with AZT, probably in combination with other drugs, or with interferons, that will be able to stop the progression of the infection leading to AIDs and death. However, I think we are also going to have many more people infected and it will remain an enormous public health problem. What we have not done and missed doing over the last two years is public education – and intensive enough and serious enough, not just chatting at cocktail parties about AIDS – but impressing on young people who enter their sexually active period in life that this virus is around, that everybody is at risk, male and female, that the risk varies a bit from one geographic region to the other, but that in certain cities, in certain areas of this country, the risk is not negligible – each time somebody, boy or girl, picks up a new boyfriend or girlfriend, he or she takes a chance of 1 in 10 or 1 in 20 of hitting somebody who is already infected and acquire the infection.
Heffner: Therefore, what about the…
Krim: And therefore…therefore sexual morals – you know, the sexual liberation, and we talked about that two years ago, and I was saying then that this has to be done – has absolutely to change, at least for a certain time, until we have a vaccine against this disease. Youth has completely forgotten that there are still venereal diseases around – because those one catches ordinarily can be treated. This one has not been treatable so far, and even now AZT can suppress the virus, can keep somebody alive, but these people, once infected you remain infected all your life. For women there is an additional consequence – the woman infected cannot have children because her children are going to be infected one after the other.
Heffner: Dr. Krim, when you were here last time, or another program we did together, someone misunderstood what you were saying and said the Dr. Krim took some delight in pointing out that sexual promiscuity, etc., can be a key to the contagion here. You weren’t taking delight in that it seemed to me.
Krim: Well, absolutely not…absolutely not. I think it is very sad. It is, in fact, very difficult to talk, to say to a young people starting in life, the kinds of things I just said – I’m very sad. We have to, but we must.
Heffner: Is there any indication whatsoever that that point of view…that that necessity, as you see it – the physical, medical necessity – that has been paid attention to, is operative?
Krim: It is…I think it has been paid attention in certain circles – among people who read and think for themselves. But this is a very limited number of people, I’m sorry to say. There are vast groups in this country who don’t think at all that AIDS is any of their concern, they don’t think that they are at risk, they still think it is some disease of some obscure, sleazy groups somewhere in New York or on the West Coast, and that’s it. And they have not changed their ways. Today, there are no serious educational programs in high schools, in colleges, in universities.
Heffner: How do you account for that? It seems suicidal.
Krim: Yes, it is suicidal. I think there is…you know, it is such a horrible situation…that there is a process of denial at work, I’m sure.
Heffner: Fear, then denial?
Krim: Yes. This is one aspect. The second one is that despite the fact that people like me have been repeating this offer and over, saying that this is not a disease of the underworld, this is a disease, period – a contagious disease – due to an infectious agent who only waits for an opportunity to go from one person to another. The infectious agent is not choosy and does not discriminate – anyone can become infected and can die of AIDS. People still don’t believe that and they think that admitting, knowing or having somebody in their family who is infected or who has AIDS is something shameful and therefore they don’t talk about it.
Heffner: Well then, you spoke about the need for public education…
Krim: So, so most people don’t realize that it’s all around us.
Heffner: Yeah, but you know, Dr. Krim, the thing that astonishes me is you spoke about the need for education when you were here and you have spoken about it again and again and again. Still we do so much less than we need to and I gather that…
Krim: I’ll tell you why.
Krim: Well, because to do education at that level, to really blanket the total population, to bombard it with educational messages, about sexual behavior, about how to use condoms when having sex, how to use spermicides, how the pill does not protect against disease,, it protects only against conception – this is the kinds of things one has to say. And this kind of intensive program has to be done by government agencies – there is no other way – it has to be done by a centralized agency that develops these messages and puts them on the air – on radio and on television.
Heffner: Is it being done at all?
Krim: No. and you know why? Because, of course, these kind of messages have to address topics that we’re not used to speaking about in public or on the television screen, including the fact that there are sexual variations between certain men and how they take place and which are dangerous and which are safe and this is the kind of thing many religious souls in this country – I don’t know how to describe them — people who cannot bring themselves to talk about certain things. They keep preventing…I know that..For example, the Center for Disease Control has issue, a few months ago, an appeal for applications to scientist or societal researchers for educational programs. Some of them addressed sex among gay men or certain sexual practices. That had to be mentioned because we had to explain what is risky and what is not… the scientists reviewing these applications had approved a number of them – they felt they were of good quality and they had married, they were correct, and so forth. They were turned down, I was told, at the level of the White House — that there were people in political circles and in agencies of the administration that have nothing to do with medicine and public health who felt that this kind of talk or this kind of subject should not be supported by public monies. And this I why we don’t have public education. They are hoping that private organizations will do that – and there are private organizations who do their best to educate the public, but we cannot penetrate every segment of the public.
Heffner: We have about forty-five seconds left. You say the administration…the government is not doing what it can and should do in terms of public education. What about research…medical research?
Krim: Well, it has done much better there. The…I think the funding has come late and has been too little – and it is still today too little. The government could take better advantage of the enormous resources there are in the universities that are not tapped sufficiently. But at least they have invested in research….the government has invested both at the NIH and outside in the universities and this is why today, within a very short time from the first appearance of this disease, we know what causes it and we know how to prevent it and now how to treat it.
Heffner: Maybe the next time you’re here we will have known how to educate against it. Thank you so much, Dr. Krim, for joining me today on The Open Mind.
Krim: I hope so.
Heffner: And thanks, too, to you in the audience. I hope you’ll join us again next time. And if you care to share your thoughts about today’s program, please write to THE OPEN MIND, P.O. Box 7977, FDR Station, New York, NY 10150. For transcripts send $2.00 in check or money order. Meanwhile, as another old friend used to say, “Good night and good luck.”
Continuing production of this series has generously been made possible by grants from: The Rosalind P Walter Foundation; the M. Weiner Foundation of New Jersey; the Mediators and Richard and Gloria Manney; the Richard Lounsbery Foundation; Mr. Lawrence M Wein; Pfizer, Inc.; and the New York Times Company Foundation.