AIDS … A Modern Plague Revisited

GUEST: Mathilde Krim
VTR: 1/28/1994

I’m Richard Heffner, your host on The Open Mind. A decade ago, when the San Francisco Chronicle published a selection of its own 1984 coverage of AIDS, it titled it “The Year of the Plague.” Well, a distinguished researcher took exception to that title here on The Open Mind because she said it conjured up images of the Middle Ages and of a total medical impotency in the face of the AIDS disaster, which she didn’t accept, and with good reason. For Dr. Mathilde Krim, then of the Memorial Sloan Kettering Cancer Center, and now chairperson of AMFAR, the American Foundation for AIDS Research, believed American science could mobilize to stop this disease, as she said, “To learn how to treat it, and to learn how to vaccinate against it.” She said on this program that, “We could get rid of it in the next ten years.”

Well, ten years have gone by, and we haven’t. And I want to ask Dr. Krim why not, and what potential there is now for doing so.

KRIM: Well, for one thing, there has not been a real mobilization. And you know for many years there was no leadership mobilizing the country and Congress to appropriate sufficient funds for research to alert the public to the need to support research and particularly education and prevention of AIDS. So we have seen not only a spread of the epidemic beyond what it needed to be, but also research has been slow in getting started. And even today we are far from having a general contribution by the scientific community, a maximum contribution by scientific community. There are a number of people, probably several hundred scientists in this country working on AIDS research. Some industrial companies, a number of them, maybe 30 or 40 companies, are trying to develop products. But all this has started much too late. The industry, the pharmaceutical industry has become seriously interested in therapies, in developing therapies for HIV disease and AIDS only in the late Eighties, 1987, ‘88, ‘89.

HEFFNER: But how do you account for this?

KRIM: So, we can count the research efforts started probably less than ten years ago. What could be done ten years ago and earlier, because the epidemic really started 13, 14 years ago, was epidemiological research. But therapeutic research started very late, and less than ten years ago.

HEFFNER: Well, you used the phrase, you said there had not been ‘real mobilization.” How could there not have been when for all of these years now, for much more than a decade, we have been, the public has been so enormously aware of, or at least it seemed to me and to others that… And you’re saying no.

KRIM: No. You live in a city where the problem is more important than other cities, in an educated community, I suppose, your social environment is highly educated and sophisticated. You are aware, your friends are aware. But you take the average American in this country, there is a bit of knowledge that it exists, there is a bit of knowledge, I would say the majority of people know it exists and know even how it is transmitted, at least they know the major way, mode of transmission, which is sexual. But this is far from understanding the gravity of the problem and applying what one knows to one’s own behavior. It is continuing to spread, because people, one of the groups at highest risk for AIDS, which are promiscuous heterosexuals, promiscuous people, sexually promiscuous people in general – but now promiscuous heterosexuals are in this group also – don’t even, for example, are not sufficiently concerned about their being tested, of learning whether they are already infected or not. Most people don’t realize that you can be infected and develop the disease over a number of months and years without having any clinical symptoms of it. They still don’t get that either. They don’t realize that there are many more people infected than we know, because most of them don’t have symptoms of disease, so we cannot recognize them as being infected. These are all notions that are not in the heads of the majority of Americans.

HEFFNER: Does that mean that you now would want more testing?

KRIM: Yes.

HEFFNER: There was a time when you didn’t feel that way.

KRIM: Well, things have changed since we last spoke.

HEFFNER: Indeed.

KRIM: Ten years ago, there was nothing we could do. We did not even understand the meaning of seropositive status. We did not understand the relationship of the virus to the disease. We were not sure this virus induced the disease. There was nothing we could do against the virus. Now we think there are certain things we can do. And, the stigma attached to the disease was clearly stronger then than it is today. In fact, one of the dangers today is that people have become a little too much used to the existence of this disease and have kind of integrated this notion in, you know, in their lives, that it exists and nothing can be done about it and that’s it.

HEFFNER: Can you integrate such a deadly threat into your everyday life?

KRIM: Well, most people don’t understand how deadly it is. And what a risk it is to everybody, and particularly to coming generations.

HEFFNER: Now, that means, what do you want to see done by way of testing? What would you think optimally?

KRIM: Well, I would like to see, not mandatory testing, as was mentioned a number of years ago, but more people asking to be tested. First of all, to know whether they have the virus or not. And this particularly so among young people who intend to start a family, young women in particular, before they become pregnant, not after, as is often done now. It is true, this disease is with us, it’s going to be with us forever. We’re going to have to learn, and I still believe we are going to learn, how to vaccinate against and treat it. But we’re never going to eliminate this virus. And right now, before we have a vaccine, we have, first of all, to listen to advice on how to avoid becoming infected, and if, for some reason, in one’s past, particularly among young, sexually active people, there are reason to believe one might have been exposed, and this is, for most people, you know, a likelihood because there is little sexual abstinence or monogamy nowadays in our society. So most people have taken chances without knowing it in the past. They should know what their status is, and then verify it once more before taking on the responsibility of fathering or mothering a child.

HEFFNER; Now, when we spoke last a decade ago, one of the concerns was, was that the testing was so imprecise. Is that still the case?

KRIM: Yes. It is still imprecise in its negative results. Positive results can be verified and rather precise.

HEFFNER: I see.

KRIM: In fact, you know, a positive result is a positive result. There is very little doubt. Negative results are imprecise. Because people can have acquired the virus and not yet developed the antibody; and the test is a test for antibody. So some people are going to test negative when in fact they are infected.

HEFFNER: You don’t want mandatory testing.

KRIM: No.

HEFFNER: But you feel strongly about the importance…

KRIM: Yes.

HEFFNER: …of voluntary testing.

KRIM: Yes, voluntary testing.

HEFFNER: Now, when do you get to the point, since when we last spoke you weren’t that involved in the question of testing, do you think you will reach the point at which you will say, I don’t like the thought, but mandatory testing?

KRIM: No, I don’t think so. I don’t think so. Although there are certain situations where testing is not mandatory but is imposed, so to speak. For example, it is already done as part of a study. But to investigate or to get a better idea of the incidence of seropositivity, of infection in the population, certain hospitals, for example, already counsel testing upon entry into the hospital. And they explain that it is for a study to find out the percentage of seropositive people treated in that particular hospital.

HEFFNER: If you had to make a bet as to the extent of that situation in the country, whatever your scientific basis, what is your assumption about how far-spread?

KRIM: Well, the conservative estimate, which is an official estimate, is, or has been for a number of years now, that well over a million people are already infected. Most of them don’t know it. But this is based on testing groups of testing groups of people at high risk, low risk, in different regions. It is an estimate. It could be as high as two million. And this is one in a hundred Americans, on average.

HEFFNER: An incredible figure.

KRIM: Which is very high.

HEFFNER: Now, you, I remember when we did another program, not just The Open Mind. We were together on a program called “From the Editor Desk.” And one of the editors later on said something, wrote something that I thought was outrageous. Felt that you felt, you took some pleasure in the notion that there is going to have to be a change in sexual practices. There was just no question.

KRIM: Yes, I remember this remark.

HEFFNER: You remember it. And I thought that that was outrageous that…

KRIM: Yes.

HEFFNER: …you would take pleasure in that. But clearly you feel so strongly that we simply do have to change sexual…

KRIM: As long as we don’t have a vaccine, yes.

HEFFNER: But we haven’t done it.

KRIM: No. This is, what there was alluded to earlier. We haven’t done it. Some people have. The gay community has, you know. And this is the paradoxical and tragic irony, in fact, that the gay community, which was, in the Seventies, the most hedonistic society around us, is one that has exercised the most self-discipline. And gay men, who acquired the infection at a high rate in the early Eighties, because we did not know of the existence of the virus until 1984, 1985, 1986 perhaps, for many people, and in the early Eighties this virus was already around and had already infected many gay men. So the danger became very great in the mid-Eighties. And they, however, educated themselves, organized their communities around the country to educate their members And by 1987 the spread of HIV in the gay community plummeted to less than one percent per year from 20 percent per year in 1984.

HEFFNER: You know, I saw “Philadelphia,” which I considered a very wonderful film. But I also had the feeling that by focusing, in an extraordinarily well done film, on AIDS in a homosexual setting, that it was part and parcel of our problem – not the solution, but the problem – in getting heterosexuals to understand the threat.

KRIM: Yes. That’s a major problem we have today. Is to understand that this virus does not choose its victims, does not discriminate. Everybody is at a certain risk of it, and promiscuous heterosexuals are at risk today, significantly so.

HEFFNER: Do you think on the college campus today there is no greater concern than there was?

KRIM: There is greater concern, but not great enough. I don’t think people are concerned enough to really change their way. In fact, we know they haven’t, to a sufficient extent. We can measure things like, such as sale of condoms, you know. It has increased by 20 percent, 30 percent over previous years. That’s not enough. We know that many young people on college campuses are not careful enough. And in addition, you know, we’re a very heterogeneous society. I often see, among very educated women, particularly in their forties, people who are terribly worried, you know, and have even given up having any sexual relationship with anybody. And at the same time, in other groups of our society, teenagers for example, adolescents typically, nothing has changed.

HEFFNER: Is that because the very young still feel that they’ll live forever, that they are immortal?

KRIM: This is one thing. And secondly, we adults have not, I think, carried out our responsibility to educate them properly. I am very much for very frank education for very young people, including making means of protection available wherever these youngsters are. This means schools, also.

HEFFNER: How sympathetic are you to the opposition to providing the means in school on the part of parents who say, “We want to introduce this subject to our children. And besides, we don’t want the distribution of condoms, because that means this is acceptable behavior”?

KRIM: Well, I am a parent. Maybe you too.

HEFFNER: Uh huh.

KRIM: Right? Aren’t we very bad at educating our children in sexual matters? I was. And I needed the help of friends to help me. And I have discussed this with many parents. And most of them admit that they just can’t do it. It’s very difficult to raise the subject, and particularly when it goes down to practical details, you know, how to use a condom properly and so forth. It’s very difficult. And I don’t believe parents can do these things. Parents can teach values, yes. Can in general terms teach the virtues of sexual abstinence until a certain age, and so forth. Beyond that, they can’t do it. And it is technocrats, teachers, counselors, nurses, who can do the rest of this education. And that is to be done in the school system.

HEFFNER: But, of course, the argument is that the primary value is being taught with the distribution of condoms and the demonstration…

KRIM: No.

HEFFNER: No?

KRIM: No. Condoms are available in pharmacies, you know. So when they are available…

HEFFNER: But we’re talking about very young children.

KRIM: But even young children know that nowadays. They are not distributed, by the way, the condoms. They are available on request with counseling. That’s a very different thing.

HEFFNER: Now, let me ask what could be done on a governmental level that has not been done? Because you feel that we have not, as a people, taken on the responsibility of education, demonstration, etcetera.

KRIM: Yes.

HEFFNER: What could be done?

KRIM: Well, we have some of it now with President Clinton. We have somebody who doesn’t mind mentioning the word “AIDS,” and has recognized the gravity, has, in fact, in his federal budget, you know, proposed an increase in funds for research, education, for prevention and care. But we have not had that for ten years before. And it was at the beginning of the epidemic that things had to be said very plainly and straightforwardly. Now, again, people have developed their own attitudes, their own interpretation of what was going on. So it’s late, it’s difficult, you know, for leadership to make people change their mind. It’s still possible, hopefully. President Clinton has been good, at least on the rhetoric and on the funding, he has been very good.

I forgot the beginning of your question.

HEFFNER: Well, I was just asking what could be done. And you feel that, you say, on the level of rhetoric and the level of funding…

KRIM: Yes.

HEFFNER: we’re now in a better situation than we were.

KRIM: Yes. Yes.

HEFFNER: What’s happening overseas? What’s happening in other countries in terms of the rhetoric and the funding?

KRIM: Not much better than in this country. You know, this country is really a world leader. Everybody is looking at what we do on things like this. What our science is doing. Certain countries, such as Sweden, Holland, Switzerland, even England, Spain, have been more forthcoming, more free in what, in the kind of educational programs the government has sponsored. They have talked openly about condoms long ago, long before we did. We just started under Clinton, But in terms of real mobilization, infusion of resources behind the research and prevention effort, they have riot been much better than we have. Perhaps worse.

HEFFNER: And the medical profession, here as well as abroad, is it doing what it must do?

KRIM: Well.

HEFFNER: One was afraid early on that doctors would turn away, feeling threatened themselves.

KRIM: Oh, they felt threatened, themselves. Some of them were worried about transmission until, you know, we understood that really the risk there was virtually nil or certainly virtually nil outside the professions such as surgery, for example. Also, physicians were not themselves properly informed about how to treat the condition. We knew nothing about it. We did not know how to treat it. And we only now, certain approaches to treatment have become well standardized and known in the medical world. The medical profession can treat people, and more and more physicians become sufficiently informed to do so.

HEFFNER: Do you find that the medical profession is doing the job of educating younger people as it should…

KRIM: No, but it’s not its job, really.

HEFFNER: You, I mean, one could say, you said before that it’s the job of the technicians. And the medical people are the technicians.

KRIM: Oh, well, in that sense, yes. You know, if practicing physicians had never been vague at educating their customers, their patients, probably they don’t do it to the extent we would like them to do, correct.

HEFFNER: I would think that the pediatrician who deals with infants, and they remain with him or her as children, and as they grow up through adolescence would be in a wonderful position, the most important position there.

KRIM: They would be, but they don’t consider it part of their job. They don’t have the time. You know, it’s very difficult. It takes time to educate people. And it cannot be a one-time process. It has to be a continuing process. The message has to be reinforced. Has to start being very simple, to becoming more and more sophisticated. And this is not something a working physician can do.

HEFFNER: You know, you said before that when we last spoke it was the homosexual community, the gay community that was largely involved in a hedonistic lifestyle.

KRIM: Yeah.

HEFFNER: That that was brought, not to an end, of course, but was strictly, considerably modified by the knowledge of AIDS.

KRIM: Yeah.

HEFFNER: What you’re saying now, I gather, is that in the heterosexual community, among our young people, we are equally as hedonistic…

KRIM: Yes.

HEFFNER: .. .equally as involved in not paying attention to the threat.

KRIM: It’s almost as much, yes.

HEFFNER: Make you want to feel sometime like shrugging your shoulders and…

KRIM: No. No, never. But it is sometimes discouraging, you know. We should have made more progress in ten years time.

HEFFNER: Does the press do what you think it should do? The media, let’s put it that way.

KRIM: The press… The media in general. The media have not been bad at all. They have tried. But, you know, the media has to come up all the time with new stories and new things to say and a fresh angle. And its getting a bit boring to talk about AIDS because we have to repeat the same things all the time. And everything we predicted ten years ago… remember our first interview. I don’t think, on the basis of what I remember, that there is one word of that interview that needs to be changed today. I made dire predictions. They have come true. So there is not much new to be said about AIDS. And it’s, again, the media have done a terrific educational job, but it’s difficult for them to keep up with it because it becomes repetitious. And when it becomes dull and repetitious, they abandon the subject.

HEFFNER: What’s going to change that?

KRIM: Integration of this issue as a serious societal issue to be talked about in the places where we do education, which are schools. At every level. Starting from early age — and not talking necessarily about sex – but talking about personal hygiene, persona) respect, respect for others. To talking about health, you know, the germ theory of disease, and then sexuality. And this happens at different ages, done by different people. But it has to become integrated in our educational message to children. With reading, arithmetic, etcetera.

HEFFNER: The first time we spoke, there was a sense of potential catastrophe in terms of the potential for the virus itself to mutate in such a way that it would spread even more widely and wildly. Is that still…

KRIM: That was not said by me at the time.

HEFFNER: Is that a consideration, though, on the part of some?

KRIM: It’s a far-out, very far-out possibility. No, there is no reason to be concerned about that. We have not seen it happen with other viruses. You know, viruses are parasites. And a good parasite does not kill its host, or it kills it very slowly. This virus kills the host, but very slowly. And it’s in its best interest to continue to do so. If anything, a natural evolution of parasites, parasites become more mild enemies rather than mare aggressive ones.

HEFFNER: I hear what you’re saying. It certainly is in our interest to listen to what you said ten years ago and what you’re repeating now. And I want to thank you, Dr. Krim, for joining me today on The Open Mind.

KRIM: Thank you very much.

HEFFNER: And thanks too, to you in the audience. I hope you join us again next time. And if you’d like to share your thoughts about our very serious, very important program today, please write: The Open Mind, P.O. Box 7977, FDR Station, New York, NY 10150. For transcripts, send $2 in check or money order.

Meanwhile, as another old friend used to say, “Good night, and good luck.”