Call to Battle

By GEORGE J. CHURCH

Ever since the advent of AIDS, two questions have been haunting Americans. How far and how fast is the incurable and almost invariably fatal disease likely to spread? And does it pose a threat to the general public -- that is, the vast majority of people who are neither homosexuals, bisexuals nor intravenous drug users?

Last week a committee of 28 biologists, clinicians, public-health scientists and other experts assembled by the prestigious Institute of Medicine of the National Academy of Sciences gave some grim answers. AIDS, according to the panel's 374-page report, "could become a catastrophe" unless the spread of the killer virus is checked. That will require "perhaps the most wide-ranging and intensive efforts ever made against an infectious disease," specifically research and education programs that would probably cost $2 billion a year, at the minimum, by 1990.

In addition, said the panel, the number of cases among heterosexuals who do not inject narcotics into their veins, though small at present, is increasing and likely to rise further. How rapidly no one can predict, but the threat is at least great enough to justify targeting educational campaigns not just at homosexuals and IV drug users, who now account for more than 90% of all AIDS victims, but at everybody.

What gave the panel findings extra punch was that they followed by only a week an equally grim report by U.S. Surgeon General C. Everett Koop that urged an all-out effort to educate the populace, beginning with young children, to the dangers of AIDS and ways to avoid them. Though they worked independently, Koop and the NAS committee each knew of the other's studies. Their reports contained little that had not been published before in the way of scientific information about AIDS or predictions about its spread. What distinguished them from previous pronouncements was the authority of their authors (the National Academy of Sciences was chartered by Congress in 1863 as a private body to give advice to the Federal Government), their uncompromisingly blunt language and the urgent tone of their recommendations. Said David Baltimore, cochairman of the NAS committee, at a Washington press conference: "This is a national health crisis . . . We are quite honestly frightened about the prospects."

Just what are those prospects? The panel endorsed five-year projections that were made by the Public Health Service last summer. Key numbers: by the end of this year, 35,000 people will have developed AIDS, and 18,000 of them will have died. By the end of 1991, those numbers will multiply to 270,000 cases and 179,000 deaths -- 74,000 new cases and 54,000 deaths during 1991 alone, costing between $8 billion and $16 billion annually in health care. Unhappily, these numbers are not mere guesswork: the vast majority of those who will sicken and die over the next five years already have the AIDS virus in their bodies. An estimated 1 million to 1.5 million people in the U.S. have been infected by HIV (for human immunodeficiency virus), the currently preferred term for the AIDS-causing agent. The academy calculates that at least 25% to 50% of them will develop the actual disease. Very few AIDS victims live more than three years after their disease is first diagnosed.

The figures need to be seen in perspective. The 54,000 AIDS deaths expected in 1991 would exceed the total of 47,319 American battle deaths during the entire course of the Viet Nam War. But motor-vehicle accidents killed 45,600 last year, and cancer killed more than eight times as many people (462,000). AIDS is not, and is not likely to become, another Black Death, decimating the population. One reason: unlike the plagues of old, it does not spread by casual contact. Surgeon General Koop, the National Academy of Sciences' panel and other researchers are unanimous and vehement on that point: AIDS cannot be contracted from doorknobs, drinking glasses or toilet seats, nor even by hugging and social kissing. The virus is transmitted most often in this country by sexual intercourse. The second most common means is by the use of contaminated needles for intravenous drug injections. The majority of children with AIDS got it from their infected mothers, before or during birth. Very rarely these days is the virus spread by transfusions or use of contaminated blood or blood products. Cases of AIDS continue to appear, however, among people who received tainted blood or blood products years ago.

The NAS panel's greatest worry is that the virus is being spread further every day, and largely by people who may not know they have it. AIDS often does not appear until five years or even longer after infection, and people who have not yet developed the disease -- and may never do so -- can still transmit the virus to others. Little if anything can be done to help those who are now infected and will fall sick over the next five years. The question is how widely the disease will spread after 1991.

Much will depend on how far the AIDS virus seeps out of the ranks of homosexual men and IV drug users and into the general population. On that subject, the National Academy of Sciences is cautious. Its report noted, rather delicately, that "there is a broad spectrum of opinion on the likelihood of further spread of HIV infection in the heterosexual population." At first glance the academy's projections seem moderately reassuring. Accepting the Public Health Service estimates, it states that "new AIDS cases in men and women acquired through heterosexual contact will increase from 1,100 in 1986 to almost 7,000 in 1991." That rise would be substantial indeed, but the total would still be small, and would represent only slightly more than 9% of all new AIDS cases expected in 1991, vs. 7% this year.

But in later years? There are some disquieting omens. Nothing in the biology of the disease suggests that once the virus enters their bodies, heterosexual men or women who do not inject drugs are any less susceptible to AIDS than homosexual men or IV drug users. Says the Public Health Service: "This virus does not discriminate by sex, age, race, ethnic group or sexual orientation." And there are now what the academy panel calls "well documented" cases of infection resulting from vaginal as well as anal intercourse, which was once thought to be implicated in nearly all cases of heterosexual transmission. Indeed, the report asserts that the "relative efficiency of various types of sexual transmission is not known."

In Central Africa and Haiti, where AIDS has spread more widely than in the U.S., the virus is believed to be transmitted now most frequently by heterosexual intercourse. Researchers disagree strongly on whether that can be taken as a preview of what will happen in the U.S., given the hygienic and other differences between those countries and America. But in the U.S. too, the risk of AIDS increases with the number of sexual partners a man or woman has: the more partners, the greater the chance of repeated exposure to an infected person. Koop goes so far as to say that "unprotected" intercourse between even a steady couple poses a risk unless the pair knows with "absolute certainty" that they have been mutually faithful for at least five years.

In any case, says Baltimore, "we are at a critical point in the progress of the epidemic" that requires an "intensive national effort" to keep AIDS from spreading further. The panel urged an all-out educational campaign to teach the populace through ads, and above all in schools, how to avoid the risk of infection. Sex education, said the panel, has become literally a life-and-death matter, and educators should use "whatever vernacular is required" to get the message across. One message, more or less in the vernacular, has already been supplied by Koop: a "rubber (condom) should always be used during sexual intercourse (vagina or rectum)" if there is any chance that a homosexual or heterosexual partner might be infected.

The Federal Government, said the academy committee, would have to organize and direct the educational campaign, and put up much of the $1 billion a year that will be required by 1990. And Uncle Sam would have to supply nearly all the additional $1 billion annually required for a vastly expanded research effort -- which must not be taken from other research efforts. This is a tall order. In fiscal 1986 the Reagan Administration committed just $234 million to AIDS research and education combined.

Despite the high hopes raised among AIDS patients by the experimental drug AZT, the panel predicts that development of a safe, effective drug to halt or cure the disease or a vaccine that would prevent infection looks to be at least five years away. The time could be even longer, the panel said, if efforts are not stepped up greatly now. In France, however, some AIDS researchers appear more hopeful. Dr. Marc Girard of the Pasteur Institute in Paris announced last week that a vaccine developed there should be ready for human trials sometime next year. The vaccine was developed by adding protein fragments from the AIDS virus to vaccinia, the virus that causes cowpox and is harmless to humans.

The recommendations for education and prevention may encounter resistance. In the view of the Roman Catholic Church, for example, a Government campaign to urge use of condoms would be encouraging people to commit mortal sin. The church regards condoms as artificial contraceptive devices whose use, even to avoid lethal disease, is forbidden. In the view of the NAS panel and Surgeon General Koop, however, action must no longer be delayed. AIDS researchers have faced an exquisite dilemma: they initially felt obliged to calm public hysteria stirred by the false idea that AIDS can be spread by casual contact, but in the process some may have played down the threat of the disease. No more. In their view, it is time for a call to battle.

With reporting by Dick Thompson/Washington, with other bureaus