10th Anniversary of AIDS

AIDS Epidemic Shifting to Poor and Dispossessed

By Malcolm Gladwell
Washington Post Staff Writer
Wednesday, June 5, 1991

In the beginning, AIDS was a disease of sexually active gay men, of single white males, of artists and professionals, of Christopher Street in Greenwich Village and the Castro district in San Francisco.

It is not that anymore.

Today, 10 years to the day after the Centers for Disease Control first reported on the outbreak of the mysterious illness that came to be known as AIDS, the images and associations evoked by the disease have changed.

Today only half of all new AIDS cases still involve gay men, and this is now an epidemic moving most rapidly and most devastatingly among intravenous drug users and minorities. AIDS, or acquired immune deficiency syndrome, is also becoming an epidemic of women and children, of the poor and dispossessed, of blacks and Hispanics, of Harlem and Watts.

This shift in the demographic face of AIDS, according to those on the front lines of the epidemic, has profound implications for the way in which the disease will be fought in the coming years.

In the first 10 years the gay community was successful in setting up social support and health care networks for those infected with the human immunodeficiency virus (HIV). But few say those systems are adequate to cope with the expanding burden of the disease as it changes over the next 10 years.

Public health officials worry that the drug users and minorities who make up more and more of the HIV-infected population do not have the resources and political support to care for their own. They worry that public support for the AIDS effort may fade if it comes to be seen as just another affliction of the underclass.

"When the image of AIDS was as a white, gay disease, it had the advantages of the activism and social power that the gay community brought to it," said Herbert Nickens, vice president for minority health at the American Association of Medical Colleges. "But as it gets perceived as a minority disease, this will change. Minority diseases, particularly those of IV drug users and their sexual partners and children, do not have great power in society. . . . The real danger is that this could be labeled as a disease of people who are expendable."

The image of AIDS as a gay disease began with the first published case report by the CDC on June 5, 1981. Five young gay men in Los Angeles had contracted a rare form of pneumonia known as Pneumocystis, a condition that later became one of the trademarks of the devastation wrought by AIDS.

Still unsure of what exactly was causing the bizarre illness -- one theory at the time held it might be linked to the stimulants known as "poppers" then commonly used in the gay community -- federal health officials wrote: "The fact that these patients were all homosexual suggests an association between some aspect of a homosexual lifestyle or disease acquired through sexual contact and Pneumocystsis."

AIDS remained principally a gay disease throughout the 1980s. But in the past two years the face of the epidemic changed dramatically, as it is expected to continue changing through the next two. The proportion of AIDS victims who were intravenous drug users has steadily increased from 17 percent in the mid-1980s to 24 percent in 1989, the latest year for which figures are complete. It is projected to reach 30 percent by 1993.

More critical, while the rate of new HIV infections has steadily declined among white gay males, the virus has continued to spread among poorer black and Hispanic groups. For example, at AIDS Project Los Angeles, that city's largest community AIDS group, the number of AIDS cases among whites went up last year by 17 percent. But cases in blacks rose by 28 percent, Hispanic cases by 38 percent and Asian cases by 60 percent.

AIDS leaders argue that this trend has profound implications for the way in which the epidemic is handled. Intravenous drug users, for instance, have more severe health problems and cost more money to care for than a traditional gay, middle class patient. Minority AIDS patients are more likely to be homeless or to live in shelters. They also do not have the same level of community support and political clout that made the gay community's efforts to cope with the epidemic so successful.

"There is no community for IV drug users such as there was for gays," said Pat Christen, executive director of the San Francisco AIDS Foundation. "It just doesn't exist. This is a very fragmented group of people who are only going to get more marginalized."

"From the beginning, the gay community owned this issue," said Mark Smith, vice president of the Kaiser Foundation in Menlo Park, Calif. "The top and the bottom, the poorest and richest, Democrats and Republicans, have all been interested in and involved with AIDS.

"This has not been the case in the black community," Smith said. "The reason is that this disease has hit a segment of the black population about which the official leadership is, at best, ambivalent. They don't have an interest in presenting these people as representative of the problems of their community."

The result is that the new groups infected with AIDS have turned to the same health care networks set up by the gay community over the past decade for its own. Those facilities already were straining under a heavy burden.

This would not be so bad if the AIDS epidemic were not entering what epidemiologists call its mature stage. In the early 1980s, before the cause of AIDS was known, CDC officials estimate that more than 100,000 people every year became infected with the virus. Today, that figure is estimated to have dropped to between 40,000 and 80,000. Because of the long gap between infection with HIV and onset of the AIDS disease -- an average of 10 years -- this decline is encouraging for the long term. But it will do nothing to avert disaster in the next few years. The huge numbers of people infected in the early 1980s are just now falling sick.

In San Francisco, this means the city will see more AIDS cases in the next two years than it did in the previous 10. Nationally it means that spending on AIDS treatment will grow from $ 5.8 billion this year to $ 10 billion by 1994.

Meanwhile, public funding for treatment has leveled off. Congress, which promised $ 850 million to local AIDS groups last year, delivered just $ 235 million. Caught between an influx of patients without strong community support and restrictions on public funds, many community health care groups say they cannot cope.

"We cannot be all things to all people," said Stephen Bennett, head of AIDS Project Los Angeles.

Worse, many AIDS leaders have begun to worry that as AIDS becomes identified as an inner-city, minority disease, the sense of urgency that permeated the first decade will fade.

"The danger is that people will throw up their hands and say this is another insoluble problem of the underclass like crack and lousy schools," said Smith.

"Our biggest problem is that the public has gotten inured to AIDS," said Tim Sweeney, director of the Gay Men's Task Force in New York. "It has joined the list of chronic urban problems in this country. We have to keep reminding people that this is not a chronic problem. It is an epidemic."

© 1991 The Washington Post Company