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This would be the book review thread, yes?
I recently finished Randy Shilts' And The Band Played On. I'm surely this book has been discussed here many times, but in short, it's about the early phases of the AIDS pandemic, starting from late 70s and ending in 1985 (the book was published in 1987). The book was actually written very well and engagingly, it is no wonder it is probably still the best-well-known "popular" work on AIDS, something I had seen referenced dozens of times before actually reading it.
It's so popular, in fact, that one of the things that I kept thinking about while reading was: how much has this book, in particular, affected how the world (over)reacted to the Covid pandemic? Let's consider some of the things Shilts talks about:
These days, the book is probably the most famous for its attacks on Reagan admin and its unwillingness to answer the pandemic early on, only belatedly getting into the game during the later phases when Surgeon General C. Everett Koop decided to take initiative on his own to send information on the pandemic to all Americans, recommend the use of condoms etc. This mostly seems to have less to do with social conservatism, though this plays a part, but rather the general small government agenda and unwillingness to use federal funds for new efforts.
Actually, this part of the narrative (about the book) might be a bit exagerrated, as Shilts basically portrays almost every public instance - not only the federal government but also states and cities, particularly New York - as slow to respond and uneager to spend money. In comparison, during Covid times, almost every government suddenly decided that money's no thing when it comes to saving lives, with many governments going quite deep in debt at least for a while.
The book is probably the second most famous for Shilts's anger against the 80s gay community, particularly its unwillingness to admit that having a new, mysterious but fatal STD going on meant that it's time to put limits on culture that encourages men having sex with hundreds and thousands of men, particularly regarding the battle by Shilts, some public health officials and a part of the gay movement to close the bathhouses in San Francisco and other cities. I've actually seen some people talk about these things - promiscuity in 80s gay culture, the bathhouse struggle - as some sort of forbidden knowledge that you are not wanted to know, even though they're front and center in, again, the best-known popular work on AIDS crisis (which was also made into an also-well-known HBO TV movie.)
Anyway, even though Covid and STDs are two very different things (a closer equivalent was monkeypox, and a lot of people seemed to fear that it would become an AIDS-like epidemic, but it seems like that after the health system moved on to implicitly treating it as a STD, it was brought to control reasonably quickly - of course, the infrastructure and culture for keeping actual STDs in control has improved considerably post-AIDS, especially among gay men), much of debates about lockdowns did revolve around places like bars and other places where a lot of people (gay and straight) mingle - usually not perhaps as closely as in the sex-oriented bathhouses, but still. Of course the devil-may-care, who-knows-if-it's-even-real, I'll-get-it-anyway attitudes like the ones expressed by number of subjects of ATBPO, like that of Gäetan Dugas, one of Shilts's gay villains, were denigrated as "plague carriers" and the like.
Alongside the bathhouse narrative, Shilts concentrated on the blood banks, which become aware at a fairly early point that their blood is contaminated and poses a considerable risk to hemophiliacs and many others needing blood transfusions. Shilts blames the profit-seeking motive, which is also mentioned when talking about the bathhouses (whose owners often made stack and were moves and shakers in the local gay communities), and there's many cases where the blood bankers and bathhouse barons are shown willing to refer to high-minded ideals about privacy and freedom when they really just cared about not losing the revenue streams. Of course with Covid, states were quite willing to run over businesses, even letting some (like bars) go under.
Shilts also shows the scientific community being unable to decide on a narrative early on (somewhat unfairly at places; Shilts almost seems to demand the scientists to have immediately converge on the correct narrative from the beginning, whether this was actually possible or not), and much energy being spent on, for instance, turf wars between European and American scientists on who actually found HIV and what to even call it. With Covid, the scientific community often seemed conspicuously willing to go in lockstep and offer recommendations even with paltry knowledge on what happens, like with the "Covid-is-not-airborne/no-actually-it-is" twists and turns, or the early decision that lab leak is not possible and all suggestions on it would be conspiracy theory, something that might actually have been mostly just European and American scientists being unwilling to do anything that would prevent cooperation with Chinese scientists on this issue.
One specific figure who was fingered as a source for must misery in ATBPO is none other than Antonio Fauci, who made an early statement that AIDS might spread by touch in some situations, leading to massive panic and increasing considerably people's unwillingness to be in any contact or touch with AIDS sufferers. Whatever Fauci's role with Covid was, it's pretty remarkable that after this AIDS debacle he still was the one who implicitly became the American pandemic czar, and I think one reason why he was so willing to take this role - fit or not for it - was the feeling that after his reputation being blackened by actions during one pandemic he now had the chance to repair it by tackling another one.
Again, COVID pandemic and its reprecussions are surely a topic that has enough material for whole libraries of analysis, certainly it can't be just be explained by reference to AIDS history, but I haven't actually seen people talk about this particular book in connection to its effect on COVID debate, so I wanted to hear some opinions on this.
Honestly, I'm hard pressed to see a real villain in this whole narrative (assuming it tries to depict one).
If someone wishes to open a brothel with exclusively syphilitic whores, while I think that's a fucking terrible idea, I don't see why it should be made illegal, as long as they weren't lying to their customers (who should also know what they're getting into). I consider the correct target for penalization/responsible for externalities to be the gay men who lied about having the disease (as in they were confident about it, not just at risk) and spread it to others. I mean, that's not just for gay men, anyone who non-consensually and knowingly infects anyone with anything deserves punishment.
While the response to the advent of AIDS is certainly suboptimal, as @gattsuru points out, that was largely an outcome of sheer ignorance and confusion rather than entirely malicious. There were no tests for a long time, no way to tell if someone had been infected (barring a small and easy to miss prodromal phase after an infection), and no way to detect contaminated blood. I'm sure that the government did less than it could because gay men were disliked and marginalized, but not to the extent that I consider them evil for it.
The cause-and-effect chain was nowhere near as taut as COVID, and look at how much uncertainty there was even with modern medicine, epidemiology and stats. You have an insidious disease that only shows up in flagrant form years or decades after you were infected, and it must have taken a while to notice that it was gay men and hemophiliacs worst hit, and then to puzzle out the means of transmission in any robust way.
As for blood donations, there exists an optimal threshold for how strictly one wishes to screen blood. I'm sure the cost-benefit analysis today, with robust screening, makes it eminently sensible to forbid those at exceptionally high risk of contagious blood borne disease. But if I'm bleeding to death and there's nothing better available, I would accept potentially contaminated blood, yes, even with 1970s medicine. Dying in a decade beats dying today.
Well, if you wish to include the touch of a tumescent penis against the rectal walls, he's not not entirely wrong. (This is a joke, begone humorless pedants)
To be fair to Shilts, he does highlight some people where the line between ignorance and confusion to at least motivated ignorance was blurry at best. One repeat character early in the book is Bobbi Campbell, and Shilts claims that he continued to go to bathhouses (allegedly, though to Shilts' skepticism, not for sex) even well after he'd started plastering posters of sarcomas outside of the baths.
Dugas (aka "Patient Zero", though this is a bit of a myth) plays a more plainly villainous role in the telling, and while some of that is Shilts exaggerating matters at his editor's prodding -- there's a rather infamous bedroom conversation that portrayed Dugas as intentionally spreading the disease, "I've got gay cancer. I'm gonna die, and so are you", that doesn't really make sense given Dugas' public positions at the time and may never have happened -- but him going to bars for casual sex while AIDS Vancouver was telling him to knock it off was pretty well-supported.
And this sort of thinking didn't die with him, or with the availability of blood tests; Shilts points to the theory that HIV required some other cofactor to progress into symptomatic AIDs. This form remained common among a weird baptist-and-bootleggers alliance of gay men and religious types if publicly marginalized into the early-00s! It was wrong as a behavior even by its own merits -- asymptomatic transmission was well-established by '85 -- but as incubation times became well-established the bootlegger side of this theory became more and more obviously self-delusion. I think the author oversells this, while downplaying other plausible arguments that were reasonably-but-wrongly held. For a lot of his focus time period, the effective advise was not to simply wrap it up or abstain from casual sex, but that far broader lifestyle (during the "GRID" days) or casual contact (until mid-1983, a lot of medical professionals believed touch or even indirect contact played a significant transmission method!) changes.
There's some other later bits about gay activists putting often-steep political demands to insure that new anti-HIV efforts would not become anti-gay efforts, most impactfully around the dawn of testing.
On the other side, Shilts' narrative is far more aggressive about the failures of virology and medical research as a class. There's some Goldilocking here: the NCI (and the original sarcomas fell under cancer) research too slow-paced, NIID research underfunded, the NIH uninterested except in the broadest health impacts, the FDA (which controls blood products) unwilling to piece together disparate symptoms to the specific disease, NIH funding too broad, statutory funding too over-specified. But the full combination did lead to a painfully slow understanding of the disease, and release and delayed adoption of blood tests, often marred by politics. These are villains in the more Brazil sense, but they're still villains by Shilts' version of events.
Re: Casual contact transmission of AIDS
One of the other great works of AIDS literature is of course Larson's Rent. Larson wrote many drafts over the years, and who had AIDS and how bad and how they got it varied throughout. In early drafts, which date to the late 80s, the hetero non addict characters are also infected, or assume that they probably are or will be from living in close proximity to infected persons. There's much more of a fatalistic tone to early drafts, everyone is going to die, even the heteros and lesbians and non addicts, and die soon.
As drafts progressed, Mark stopped having, then stopped assuming he would get, AIDS, and Roger's infection was more clearly tied to intravenous drug use and his dead ex rather than just sort of having it because idk reasons. Much of Mark's character arc becomes about surviving his friends, as Larson did, and documenting and immortalizing his dead and dying friends, but also the strange isolation of being the survivor, the normie of the group, the straight white non addicted ally.
Much of this reflected the progression of medical knowledge in real life, and the final script in turn has become more a period relic than a reflection of modernity, by the time the movie came out it had a totally different valence. Treatments were different, prognoses were different.
The song that really has the most currency to today's world, and best reflected how the world would progress, is probably Santa Fe, which predicted without realizing it the development of the restaurant industry in small towns across America.
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Shilts actually doesn't spend that much time in the book on the specific "Patient Zero" claim, which seems like a bit of a red herring by Dugas supporters to concentrate on anyway, but there's multiple scenes of people reporting that Dugas (or someone matching Dugas's description) knowingly bragged of spreading gay cancer or the disease, not just the most infamous line.
Yes, where I felt Shilts was being the most unfair was the parts where he accused the authorities of just doing something wrong but then had multiple conflicting views of what they were doing wrong. I also noted that Shilts blames the media for not reporting on HIV earlier and more aggressively, but many of the cases where media reported on it they seem to just have spread wrong views or caused panic; wouldn't earlier and heavier reporting just have led to more of that?
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I'm certainly advocating for people who knowingly and non-consensually infect others with a lethal illness being slow roasted over a fire. If Douglas was fucking around, he deserves to find out, and not his unwitting partners.
My understanding is that HIV doesn't usually kill you by itself, it's the immune suppression that leaves you open to everything else (yeah, is it the bullet, gun or shooter who kills someone etc etc). But I think it's reasonable to call that a "cofactor", if you miraculously managed to keep a person with AIDS in a perfectly sterile environment and scrubbed their microbiome, I'd expect them to live a lot longer (not that deleting a microbiome is a good idea in the least).
Even the sarcomas are due to opportunistic infection by HHV-8 and friends.
So a cofactor isn't really a bad description as far as I'm concerned.
I don't blame them, I can easily see how it could have gone that way. Of course, I am not necessarily opposed to mandatory testing, for human beings who have any reason to interact with anyone else, which is just about all of them. I've browsed enough /r/Grindr to know that while some of the more fastidious ones can make a song and dance about using condoms, getting tested and PREP, if the bussy is tight enough they'll usually relent. I'm sure most straight men would do the same, if they had even the same OOM odds of getting casual sex on demand.
Looking at the horndog behavior of gay men today, even accounting for how HIV has become largely inconsequential with modern anti retroviral therapies, I think revealed preferences strongly suggests many/most of them are willing to die sooner if it means they can bareback more partners. Sure, I have nothing against them for doing so, that's their prerogative, and I doubt there's a significant number of utterly naive gay men around who have no idea what that practise entails.
I could well be overstating my competence, but if I was in charge of the CDC or FDA, I think I could, at least with a bit more study of epidemiology and stats than my standard curriculum provided, have done a better job than the incumbents during COVID. Certainly I would have at least deferred to superforecasters or polymaths like Zvi much earlier, if I felt I couldn't handle it. I would certainly have pushed for the end of lockdowns and masking much earlier than they petered away.
But putting myself in the shoes of the FDA/CDC in the 70s? I can't see myself doing better really.
My personal definition of villainy, even for institutional incompetence or sub-optimality, isn't that harsh.
There's an increased rate of certain wasting cancers that start to occur after certain thresholds of HIV infection hit, but that wasn't recognized until the late 80s, but the theory I'm motioning around was a little different.
The (later disproved) hypothesis was not that HIV alone couldn't directly kill you short of other external factors, but that it would not progress to immune deficiency in a large portion (usually 50-95%) of those who carried the virus: either their immune systems would fight it off, or it would only have some marginal impact that would never progress to recognizable symptoms. Usually the claim was that full-blown AIDs was limited to those who abused certain hard drugs or had diseases like hepatitis, though more rarely they'd point to a genetic or full-body health version.
This wasn't as crazy at is seems at first glance -- some healthier people, and those with lower initial viral exposures, often did have much longer incubation periods, at a time where all of the virologist modelling expected an incubation time in the area of months or a year. And some of the craziness that did come about wasn't just limited to the self-motivated gays, as even before HIV was isolated or AIDS formalized, the NIH spent as much time seriously entertaining theories about poppers or sperm causing the immune deficiencies due to their chemical makeup, rather than a viral contagion. Shilts has a section where one of the early gay activists does a statistical analysis for the known cases among the (wildly) sexual active men, their expected number of sexual partners, and claimed times of original infections a year earlier, and then comes up with some astronomically low odds ratio (billions-to-one?) for the then-current number of cases.
But then it turned out the disease couldn't be transmitted casually, and almost all of the healthy people in that analysis ended up just being in the incubation stage, probably had reduced T-cells even at the time, and eventually developed symptomatic AIDS, and a large portion (around two-thirds?) died before protease inhibitors were on the market.
That's part of it, but there were also expectations that the tests could and would be used as a proxy -- both to blacklist HIV-positive men from places and activities where they would not be at unusual risk of transmitting the virus, and to Notice men who got tested repeatedly (even if they tested negative) as gay and having gay sex at a time where this was often illegal.
Dunno. It's easier, looking back that far, to see what of our vision is hindsight, but there's also a lot more fog between the mistakes of that era and today. Shilts focuses a lot on the homophobia -- and while he exaggerates the sense that the CDC didn't care about gay men dying, he isn't totally unfounded -- but there was a lot of fatheaded provincialism and simple status quo bias, too.
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