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The Invention of Patient Zero

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Lacking more evidence, many AIDS experts have questioned why news of this middle-aged man’s declining health went any further than this. “This is an unusual virus in its resistance patterns. That’s important,” says Dr. Howard Grossman, executive director of the American Academy of HIV Medicine. “But there’s nothing that suggests this is the beginning of an epidemic.”

On the same Saturday Markowitz got the alarming lab results, he e-mailed the New York City Department of Health. The alert reached Dr. Susan Blank, the assistant commissioner for the Sexually Transmitted Diseases Control Program, on Monday, January 24. According to Markowitz’s remarks in February, his dealings with them were heated. “The patient is sick in four months! He never got better really. Intractable pharyngitis, twenty-pound weight loss, bed-bound fatigue. These are bringing me back to the days of the eighties, and it frightened me so much that I stood on my soapbox and screamed and screamed and screamed until they listened.”

The news reached Frieden within a week. Appointed by Mayor Bloomberg in 2002, Frieden is an activist commissioner widely respected for his medical instincts and his political courage—his steady hand guided the administration through its biggest medical crusade to date, the successful and politically risky campaign to ban smoking in public places. But before entering politics, Frieden was an infectious-disease doctor, specializing in drug-resistant tuberculosis. For much of the past eighteen months, AIDS has been his top priority, and he has earned high marks so far. As early as this month, he expects to announce a controversial new approach to the epidemic in the city, which is still the AIDS epicenter of America. Citywide, more than 110,000 are infected—and 20,000 of them don’t know it. According to a draft of the report, which was leaked to me, he wants to change the state laws in order to streamline the consent process, making an AIDS test like other blood tests, while making AIDS testing much more widely available. “Knowledge is power,” he told me in an interview in his Chambers Street office several weeks ago. “Most people who know their status . . . do the right thing. So increasing the proportion of people who know their status is probably the single most important thing we can do to reduce the spread of HIV.”

Some activists are disturbed about this change. “It seems to me that’s a slippery slope,” says Tracy Welsh, the executive director of the HIV Law Project in New York. “Pretty soon we’re looking at universal testing—i.e., mandatory testing . . . And then what? Restrict their civil liberties? Criminalize their behavior?”

Frieden has been known to push the civil-liberties envelope in order to contain health risks. In New York in 1993, he helped establish detention centers for people with TB who refused to follow doctors’ orders. But while the commissioner has expressed grave concerns about patients who are courting HIV mutation by not following their drug regimens, he’s said he has no plans to make testing compulsory. Instead he wants to track patients’ viral profiles case by case and help their doctors find a better regimen if their virus is mutating. For the most part, AIDS leaders take him at his word. In fact, he enjoys support from traditionally antagonistic groups like the National Black Leadership Commission on AIDS, GMHC, and the Harm Reduction Coalition.

At first, Frieden was skeptical of the supervirus case. “I asked both David and Marty, ‘How do we know this isn’t severe acute retroviral syndrome?’ And I asked people from around the country, too. ‘Could this be just a severe conversion reaction?’ And they said, ‘No.’ ” He also challenged the conclusion that the patient was newly infected. What if the patient’s flu symptoms were caused by something else—something as simple as the flu?

For the next week or so, Frieden conferred with other experts, including AIDS specialists at the Centers for Disease Control and Prevention. Then, on January 31, Department of Health investigators interviewed the patient, hoping to develop a list of those he may have exposed. However, because a majority of the original patient’s contacts were anonymous, Frieden says, “we started with less than a 50-50 chance.” Those men whose names he recalled were invited to talk; many reportedly declined.

He also contacted three dozen blood laboratories in the U.S., Canada, and Europe and asked them to canvass their records for evidence of viruses that matched this patient’s nucleotide sequences—potentially hundreds of thousands of samples.

Frieden then weighed various additional options, and sent out a blast-fax to a network of doctors. But he worried that some of these men weren’t symptomatic yet or had mistaken their symptoms for something more benign. “You want to generate demand,” he says. “You want people to think, Oh, I just had unsafe sex a couple of weeks ago, and I’ve got now what feels like a really bad viral syndrome. Maybe I should remind my doctor that they should test for HIV now. It’s important to do that, because the viral load and infectiousness of someone who’s recently infected with HIV is astronomically high.”

Ultimately, the decision to hold a press conference was Frieden’s alone. He assembled some prominent community leaders to join him on February 11. The next day, the story dominated the covers of papers around the globe.

The announcement detonated a long-smoldering debate in the gay community over sexual responsibility. “We are murderers, we are murdering each other,” says Larry Kramer, whose new book, The Tragedy of Today’s Gays, was published this month. “If intelligent, smart people are unwilling to take responsibility 100 percent for their own dicks, I don’t know how you stop the killing.” Some, like the columnist Dan Savage, saw in the case a reason to bring on a new penalty phase for prevention activism. “There’s a great deal of anger and frustration among gays and lesbians at the never-ending, nonstop coddling and compassion campaign that passes for HIV prevention,” he says. “There will be no sympathy when this happens to us again. We are not going to be the baby harp seals the way we were in the eighties and nineties. We picked up the same gun and said, ‘I hope it’s not loaded this time,’ and pulled the trigger again. And I’m gay—imagine how straight people feel.”


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