“Patient Zero”: The Absence of a Patient’s View of the Early North American AIDS Epidemic

Summary

This article contextualizes the production and reception of And the Band Played On, Randy Shilts’s popular history of the initial recognition of the American AIDS epidemic. Published over twenty-five years ago, the book and its most notorious character, “Patient Zero,” are in particular need of a critical historical treatment. The article presents a more balanced consideration—a “patient’s view”—of Gaétan Dugas’s experience of the early years of AIDS. I oppose the assertion that Dugas, the so-called Patient Zero, ignored incontrovertible information about the condition and was intent on spreading his infection. Instead I argue that scientific ideas in 1982 and 1983 about AIDS and the transmissibility of a causative agent were later portrayed to be more self-evident than they were at the time. The article also traces how Shilts’s highly selective—and highly readable—characterization of Dugas rapidly became embedded in discussions about the need to criminalize the reckless transmission of HIV.

“I am trapped in a dungeon where the guards wear white coats,” he pleaded. “Please rescue me.”

—The character of Gaetan Dugas in And the Band Played On, 1987¹

I feel like an allien [sic].

—Gaétan Dugas, January 1982²

On a sunny but bitterly cold winter’s day in late January 1982, Gaétan Dugas left his apartment in downtown Montreal to post a letter to Ray Redford, a former lover in Vancouver with whom he remained friends. As he hurried through the snow-filled streets near the city’s emerging eastern gay village, Dugas may have pondered the contents of the message he was sending, in which he had reflected on his recently troubled state of health.

Dugas began his letter by complimenting Redford on his attractive new partner. “Obviously all the hot men are on the West Coast. [He] Has beautiful eyes & an inviting moustache. Really Handsome!!” He continued—with words and spelling that hinted at his acquisition of English as a second language—by providing his friend with an update on his health, and thanking him for his concern. “Well, my mind is finding peace again. Thank you for your encouraging letter—it is the best medicine so far.—You are right I must upgrade my attitude towards a full recoverage—but you know, there is always the storm that strike you when at least less expected.”

Evidently Redford had asked, in a previous letter, some questions about “gay cancer” based on an article he had read. Dugas noted that he could only have “gathered very few informations off that article,” but attributed this lack of knowledge to the generally poor level of research about the disorder: “it was writing by the only sources they had!” He added that he found taking vitamin A to be “very good, so I overdose myself everyday.”

Dugas thanked his friend for an invitation to visit him in Vancouver, adding “I will hurry to grow my hair—even if you think a look better.” Having shaved his head in anticipation of chemotherapy, Dugas felt self-conscious without his usually immaculately styled blond locks, a fact that compounded his altered sense of self from being sick with cancer (see Figure 1). “I feel nude,” he wrote, “& too many people turn around when I walk in the city.” He added, “I feel like an allien ,” underlining this thought with a single stroke of his pen.

Evidently, he drew a warm comfort from their correspondence. “It is always a great please to read you,” Dugas confided, “and look forward to your letter.” He ended the message by noting that he was waiting for the weather to improve so that he could visit his family who lived in a small community on the outskirts of Quebec City; “but as I speak to them regularly, my parents send you all their Best Wishes for this New Year! Love & Affection [/] Gaétan oxo.”³

Introduction

Much has been written about Gaétan Dugas, his sexual exploits, and his controversial refusal to obey the recommendations of public health officials in the early 1980s. Dugas was the gay Air Canada flight attendant at the center of the “Patient Zero” myth: the man who supposedly introduced the acquired immune deficiency syndrome (AIDS) to the United States. Dugas has been described by the journalist Randy Shilts—in a portrayal later echoed by newspapers around the world—as “the Quebeçois [sic] version of Typhoid Mary.”⁴ Shilts’s controversial but highly popular history of the initial recognition of the American AIDS epidemic, And the Band Played On (hereafter Band), has drawn criticism for its reliance on rumor and hearsay, and for its overimaginative reconstruction of the thoughts of the people it portrays, particularly those of the flight attendant.⁵ Yet this work remains the main source for virtually all discussions of Dugas. For his book, the journalist drew on hundreds of interviews, including

Figure 1.

Gaétan Dugas, Kaposi’s sarcoma patient, 1981; black-and-white photograph, 22.8 cm high by 15.3 cm wide, Ray Redford’s personal papers, Vancouver. Although the photograph appears to have been professionally produced, no copyright markings appear on the verso. There, according to Redford, Dugas had written, “All my affection to you Ray, Gaetan [/] June 1981.” Photograph courtesy of Ray Redford (scanned image emailed to author, January 7, 2008). Dugas cultivated a cutting-edge look even while undergoing chemotherapy; the animal print of his headband was one of the most fashionable patterns that month; “Notes on Fashion,” New York Times, June 16, 1981, B14.

the testimony of physicians in San Francisco and New York. Some—like Marcus Conant and Alvin Friedman-Kien, two dermatologists who treated the flight attendant for his Kaposi’s sarcoma (KS) skin cancer—accused Dugas of being a “sociopath.”⁶ Shilts also re-created a November 1982 confrontation between one of his book’s heroines, Selma Dritz, a San Francisco public health official, and Dugas, in which the flight attendant declared that it was his right to do what he wanted with his body.⁷ Dugas’s reported refusal to give up sex, in the face of allegedly strong evidence suggesting the sexual transmissibility of an AIDS-causing agent, is still often cited as proof of a profound disregard for social responsibility.⁸ As this article demonstrates, his name would also frequently appear in calls for criminal sanctions to prevent such behavior.

Some historians appear to have taken Shilts’s words at face value. Though acknowledging that the flight attendant was “both an example and a caricature” and expressing skepticism about the claim that Dugas had brought the infection to the United States, Mirko Grmek wrote that Dugas had “sown the disease and death all along his route, at the rate of about 250 partners per year.” Citing only Shilts’s book as his reference, the historian surmised of Dugas that “a kind of deaf rage against fate had seized him, a desire for vengeance. In a medical interview, he had shamelessly declared, ‘I’ve got it; they can get it too.’”⁹ Similarly, Dugas garners mention in Peter Baldwin’s impressively wide-ranging synthesis of responses to AIDS in the industrialized world. Citing Shilts, Baldwin argued that an example of “cases that most would agree deserved censure [was] the epidemic’s Typhoid Marvin, Gaetan Dugas,” whom the historian described as “the spectacularly promiscuous and conscienceless airline steward who disseminated HIV [the human immunodeficiency virus] transcontinentally.”¹⁰

Cultural theorists, including Douglas Crimp and more recently Priscilla Wald, have criticized the way by which Dugas came to be categorized as “Patient 0” by the CDC and “Patient Zero” by Shilts.¹¹ Crimp focused on Shilts’s construction of Dugas as “the book’s arch-villain,” while Wald questioned the scientific validity of the evidence underlying Dugas’s transformation into “Patient Zero.”¹² They agreed that Shilts’s portrayal of Dugas was highly problematic; both also gave favorable mention to Zero Patience (1993), a film that merits greater discussion than space here allows.¹³ A unique agitprop musical, the Canadian director John Greyson’s film leveled a strong critique of the blame laid upon the flight attendant by Shilts, the media, and the public. The film’s spiritual roots can be traced to a decade earlier, when groundbreaking organization on the part of individuals with AIDS led, in June 1983, to a statement issued by the Advisory Committee of People with AIDS at a gay and lesbian health conference in Denver. The “Denver Principles” explicitly rejected the “passivity” of labels like “patient” and “victim” in favor of the more empowering “people with AIDS” or “PWA” moniker.¹⁴ Individuals with AIDS were challenging the notion that they were patients, or indeed patient—developments that would only grow more pronounced with the treatment activism of groups like the AIDS Coalition to Unleash Power (ACT UP) from 1987 onward. It is worth noting that uncovering new evidence about the flight attendant’s lived experience, as one of the first diagnosed cases of AIDS in the recognized North American epidemic, was not central to Greyson’s argument (nor was it a priority for Crimp or Wald). Thus, although these three critics have been influential in complicating the flight attendant’s status as “Patient Zero,” they have not added any substantially new information to the details about Dugas initially provided by Shilts in his book.

Roy Porter, writing in 1984 as fears of the newly discovered epidemic began to take hold in Europe and North America, acknowledged the difficulty of accessing “the patient’s view” in a history of medicine focused on physicians. Nonetheless, he challenged historians to rediscover how “ordinary people in the past have actually regarded health and sickness,” as this was an important “counterweight” to a history of doctors’ efforts.¹⁵ He noted that critics of patient-focused histories would point out the methodological obstacles, namely that it was predominantly physicians who left records, effectively rendering patients mute.¹⁶ Furthermore, because access to medical records is so often restricted to protect patient privacy, modern patients’ voices are, in a sense, doubly muted.

Disciplinary conventions and challenges of access may both have contributed to the lack of effort expended by other scholars to consider Dugas’s viewpoint. Wald, who devotes considerable attention to the scapegoating of the flight attendant, appears to dismiss the idea as unworkable, writing simply that “there are no historical records that document exactly what Dugas thought or did in private.”¹⁷ Here, I show that some traces do exist—the letter quoted at the beginning of this article, for example—and argue that it is worthwhile to search for and build upon these. Scarcity of sources documenting physician–patient interactions can have the beneficial effect of encouraging historians to think more expansively about health care encounters. More recently, Flurin Condrau has reemphasized Porter’s suggestion that historians should extend their inquiries beyond the narrowness of the patient–physician binary to consider the broader interactions a sick person might have in their struggles with ill health. Accordingly, I consider evidence from other individuals whom Dugas would have encountered in his sick role—not simply doctors, but also public health officials, patients, AIDS organization volunteers, and friends—to gain more insight into his thoughts, actions, and responses to his disease.¹⁸

Medical accounts of the epidemic have made it clear that, after several decades of growing confidence about their ability to treat infectious diseases, physicians experienced the appearance of the first recognized cases of AIDS in the late 1970s and early 1980s as a significant paradigm shift.¹⁹ Sociologist Steven Epstein and historian Jennifer Brier have each examined the fierce, interconnected debates that ensued at both the expert and lay levels about the causes of the syndrome. These debates would characterize a period of tense uncertainty that lasted until the ascendance and consolidation of a new paradigm in the spring of 1984—a shift Epstein labels “the triumph of retrovirology.”²⁰ The uncertainty that such discussions raised for members of the lay public recalls an earlier historical example, that of “Typhoid Mary” Mallon, though for different reasons than Shilts’s comparison implied. In her sensitive examination of the Irish American cook’s life in the late nineteenth and early twentieth centuries, Judith Walzer Leavitt explored the coping difficulties experienced by an individual when the terrain of scientific and medical knowledge dramatically shifted around her vantage point.²¹ Mallon faced repeated and lengthy incarcerations when the scientific and medical authorities of her day modified their way of imagining disease transmission in response to novel observations. Their new paradigm allowed for the existence of healthy typhoid carriers, capable of transmitting infections while displaying no external signs of disease. This shift did not translate into Mallon’s worldview, and her reluctance to concede to new public health demands left her vulnerable to demonization in subsequent historical accounts. Not surprisingly, Leavitt specifically compared the experiences of Mallon and Dugas, both being vulnerable to public health scrutiny following their identification as disease “carriers” by experts.²² This article extends this comparison as it investigates a key difficulty presented by such paradigm shifts: the challenges faced by individuals whose behavior comes to be judged by a new paradigm’s standards.

The article has three chief aims. First, I provide some much-needed context for the production of Shilts’s popular history and its most infamous character. A 2007 USA Today article listed the bestselling Band, alongside A Brief History of Time and The Satanic Verses, as one of the most influential books of the previous quarter century; more recently, it was selected by the Library of Congress as one of eighty-eight “Books That Shaped America.”²³ It received a controversial reception when it was first published in 1987; now over twenty-five years old, it is in particular need of a critical historical treatment. The second aim grows from the first: I present a more balanced treatment of Dugas’s experience of the early years of the AIDS epidemic, from his initial diagnosis with cancer in May 1980 to his death in March 1984.²⁴ I oppose the assertion that Dugas ignored incontrovertible information about AIDS and was intent on spreading his infection. Instead, I argue that scientific ideas in 1982 and 1983 about the condition and the transmissibility of a causative agent were later portrayed, by Shilts and others, to be more self-evident and narrowly cast than they in fact were at the time. Third, I demonstrate the manner in which Shilts’s highly selective—and highly readable—characterization of Dugas was taken up in the period immediately following the book’s release and became embedded in discussions about the need to criminalize the reckless transmission of HIV.

I draw upon archival sources including Shilts’s personal and professional papers, deposited following his own death from HIV in 1994, from the files of the Reagan administration and the Presidential Commission it created to deal with the disease in 1987, from an extensive series of oral history interviews I conducted during my doctoral research, and from published sources including legal journals, the gay press, and more widely circulated newspapers. Throughout, I have tried to keep several questions in mind. To which sources would a gay man turn to obtain what he perceived to be accurate information about a growing risk to his health? How would he have perceived the advice of doctors and public health officials? At what stage did the threat of AIDS move from the realm of distant to present danger? And, crucially, in what theories of causation and cure might he have believed? Bearing these questions in mind is essential if we are to position Gaétan Dugas’s response to AIDS in a historically sensitive manner. Doing so also affords us a better understanding of the politics of knowledge during epidemics—where political sympathies can influence one’s ability to access and trust information that might offer protection from emerging disease threats.

Randy Shilts’s Research for And the Band Played On

“It’s funny,” a thirty-six-year-old Randy Shilts mused while reflecting about Dugas in a 1987 interview with the Advocate, the prominent American gay newsmagazine. “He was the one person in the book I wasn’t looking for. He just appeared. Everywhere I turned in doing the research, his figure arose.”²⁵ The Iowa-born and Illinois-raised journalist had drafted his proposal for a book on AIDS in May 1985, while reporting full-time on AIDS for the San Francisco Chronicle. Devastated by the toll that the epidemic was taking on his adopted home of San Francisco and convinced that widespread homophobia was impeding an effective response, Shilts decided that a book chronicling the first years of the epidemic might represent the best chance of a political intervention on the national stage.²⁶ Following rejections from several publishers, the project was narrowly approved by St. Martin’s Press, with which Shilts had released his first book, The Mayor of Castro Street: The Life and Times of Harvey Milk, in 1982. The publisher granted him an advance of sixteen thousand dollars for travel and expenses, funds that he quickly depleted through extensive long-distance telephone interviews.²⁷

Shilts’s archived book proposals for Band make clear the approach he would adopt for his history. He intended to write a book with heroes and villains, to explain how “[a] disease unheard of just four years before—and without a name until 1982—had swept through every corner of the nation, seizing 10,000 lives.” How, Shilts asked, “did such a deadly epidemic . . . spread so thoroughly through America before it was taken seriously?”²⁸ The journalist highlighted the areas that he felt ought to have worked better: “the world’s most sophisticated medicine and the most extensive public health system . . . an amply financed scientific research establishment . . . , the world’s most aggressive media institutions . . . [and] a substantial political infrastructure” in the gay community.²⁹ Since the book was structured around “the lives of a core of characters,” Shilts promised that “AIDS at last will leave the realm of dry science writing and become firmly enmeshed in the lives of flesh-and-blood people,” resulting in “provocative conclusions about how AIDS became so entrenched in America.”³⁰ “Put simply,” he wrote, “these will be the heroes in a conflict with—and to some extent triumphant over—the book’s villains.”³¹

Another proclaimed goal for Band was to name names. Interviewed in 1987, Shilts remarked, “I feel that the problem with the epidemic now—and a reason for the hysteria—is that so much about AIDS has remained so mysterious. The medical literature will talk about an individual as Case A or Patient Zero, and it doesn’t give that person the dimension of being really human. I felt that by saying these are flesh-and-blood people with real names, I would bring home the reality of the epidemic and make it far less frightening.”³² The irony of this statement is remarkable, given the caricature of Gaétan Dugas that would emerge from his book.

At the outset of his writing, Shilts was familiar with the Los Angeles cluster study, one of the first investigations conducted by the U.S. Centers for Disease Control (CDC) into the new syndrome. In this 1982 study, a number of patients with KS and other opportunistic infections in Los Angeles and Orange Counties were linked through sexual contact.³³ Prior to the discovery of a virus, the cluster study—later powerfully conveyed in a neatly arranged diagram representing sexual connections between a number of early AIDS cases—was invoked as the best evidence, albeit circumstantial, for a sexually transmissible agent (see Figure 2).

William Darrow, the CDC investigator who was eventually able to expand the Los Angeles cluster to connect forty cases in several cities, has repeatedly maintained that the study was always meant to investigate the transmissibility, and never the origin, of the newly recognized syndrome. He acknowledged in a 2008 interview that the term “patient O”—the letter “O” abbreviating the patient’s “Out[side]-of-California” residential status—evolved within the CDC to become the numerical “patient 0.” Nevertheless, Darrow downplayed the more capacious definitions associated with the word “zero”:

Figure 2.

“0” at the center of the Los Angeles cluster study; black and white diagram, 13.5 cm high by 11 cm wide. Reprinted from David M. Auerbach, William W. Darrow, Harold W. Jaffe, and James W. Curran, “Cluster of Cases of the Acquired Immune Deficiency Syndrome: Patients Linked by Sexual Contact,” Amer. J. Med. 76 (1984): 487–92, 488. ©1984, with permission from Elsevier.

I didn’t start using the term “Patient 0” until other people had used it, and I don’t—it probably came from CDC, but I don’t know . . . who the first one was. But probably when they wrote it down “Patient O,” they went around talking to one another about “Patient 0” and so that’s how he got his name. . . . Because everybody said that this is “ground zero,” you know, this is how the epidemic started, and I want you to know that I never said that he was the first case in the United States, that he brought, ah, this, this condition to America.³⁴

Thus, despite its pioneering—and suggestive—use of “patient 0” to describe the study’s index case, the cluster study did not set out to identify the first American cases of AIDS.³⁵ Instead, “patient 0” was seen to represent an important link between cases of the new syndrome on the country’s East and West Coasts. Initially, the incubation period—between exposure to an infectious agent and display of symptoms of an AIDS-related infection, such as the normally rare KS skin cancer—was thought to be similar to that experienced by renal transplant recipients who were on immune suppression medication, between seven and fourteen months.³⁶ By the time that Shilts was writing his book in 1986, however, researchers had extended the incubation period for AIDS from several months to several years of asymptomatic infection.³⁷ This extension cast doubt on the significance of many of the links depicted in the cluster diagram and any inference that “patient 0” played an important role in the sexual network under study.³⁸ Indeed, Shilts himself had written an article acknowledging this longer incubation period in 1985.³⁹ Nonetheless, the storytelling potential of the cluster study’s central figure captivated the reporter, who later explained, “In the middle of that study was a circle with an O next to it, and I always thought it was Patient O. When I went to the CDC, they started talking about Patient Zero. I thought, Ooh, that’s catchy.”⁴⁰

Shilts had written a number of articles on gay health issues since becoming a contributor for the Advocate in 1975, often choosing topics with which he had intimate experience, such as alcoholism and hepatitis.⁴¹ A deep and pressing drive for professional success and career advancement led the journalist to moderate the permissive attitude he had developed toward drinking, taking drugs, and sexual contacts in his youth. As the son of an alcoholic parent and a recovering alcoholic himself, he knew the personal risks involved if he used drugs or alcohol too heavily.⁴² Similarly, he had become wary of the pursuit of frequent sexual partners following a painful bout of hepatitis in 1976, shortly after he arrived to live in San Francisco. The experience, he later wrote, “put me out of full-time work for 15 weeks, wreck[ed] me financially, disrupt[ed] career plans and . . . [left] me with only a fraction of my normal energy.”⁴³ “Barely twenty-five years old,” it made him confront the possibility of an early death from liver failure due to a sexually transmitted disease: “all because I had slept with the wrong person sometime last Spring.”⁴⁴ These experiences foreshadowed the blame he would later attribute to Dugas and others whose infections were passed sexually. They also shaped his emerging sense of self as a moderate-acting, straight-talking reporter, who had survived what he viewed as the excesses of life in the gay fast lane and lived to write about them.

Shilts’s work on gay health issues allowed him to develop a number of medical contacts, several of whom were later involved with the CDC’s early epidemiological work on AIDS. He begged for them to give him clues to the identity of “Patient Zero,” but beyond mentioning that the man was a Canadian who traveled frequently—details disclosed in 1983 in discussions about the cluster study—they refused to give him a name.⁴⁵ Shilts persisted, making a point of asking about “Patient Zero” wherever he went. He soon received answers. A January 1986 interview with Dan Turner, a long-surviving person with AIDS based in San Francisco, generated the name “Gayton” for a “cute” Canadian airline steward who had apparently received chemotherapy since 1980.⁴⁶ While on a research trip to New York a month later, Shilts was rewarded with more detailed information. Paul Popham, then president of the Gay Men’s Health Crisis, casually remarked in his interview that yes, he had known “Patient Zero” to be Gaétan, that he had subsequently seen Gaétan in Vancouver, and that Popham’s former boyfriend—who had subsequently died of AIDS—had dated the flight attendant. Shilts would later explain to another reporter, “I realized that Paul, who had visible lesions on his face, was dying from a virus from this guy. It was like I was seeing the legacy of this person and his virus.”⁴⁷ Shilts’s position might best be summed up by his later description of this moment in an interview: “The worst day, which I’ll never forget . . . [was] the day I discovered that Gaetan Dugas was Patient Zero and was conceivably the person who brought the disease to the United States.”⁴⁸ In this statement, Shilts posited Dugas’s significance as a dangerous foreigner bringing in disease from abroad and threatening the American public’s health, a trope that would have resonated with many of his book’s readers, given the U.S. government’s moves in 1986 and 1987 to exclude noncitizens with HIV.⁴⁹ When this role was combined with scenes from Band in which Shilts depicts Dugas as deliberately infecting other men, the result was a horrifying portrait of an apparent sociopath leaving, as Shilts put it, his “legacy” all over the United States through “his virus.”⁵⁰

One problem Shilts faced in writing Band was space. His history followed dozens of characters in a month-by-month and sometimes day-byday chronicle of the early years of the U.S. epidemic. While writing his first book, Shilts had become enamored with James Michener’s writing style in Hawaii. He deliberately modeled his books on Michener’s work, taking people, as he put it later, and “hav[ing] them represent sort of different forces in history and different social groups.”⁵¹ It appears that Dugas, in Shilts’s history of AIDS, was to exemplify those who continued to have sex during the epidemic’s early period of uncertainty. I would venture further: in his book proposals, Shilts did not list “Patient Zero” as a character, since it would be an additional half-year before the journalist would uncover Dugas’s identity. One character was included, however, in his originally proposed list: “the epidemic.” “To a large extent,” Shilts wrote, “the disease itself is the major character. In the beginning of the book, the spreading infection lurks insidiously and mysteriously, appearing in manifestations which few understand. Quietly, the infection proliferates—to a large extent, before it is even detected. As the book progresses, the masks that have hidden the face of this enemy fall away as more becomes known about AIDS.”⁵² I contend that Shilts gradually combined the originally planned “Epidemic” character with the information he was gathering about Dugas to create a deeply powerful figure of evil, and, as other critics have suggested, in doing so invested the virus itself with agency.⁵³

Dugas’s sexual exploits, in a time before AIDS was conclusively demonstrated to be caused by a sexually transmissible agent, became conscious acts of infection in Shilts’s book, acts that again recall the intentionality highlighted in some of the more extreme versions of the “Typhoid Mary” myth. When he was writing Band, Shilts seems to have viewed Dugas’s noncompliance with health officials in a time of great uncertainty as the embodiment of inhuman behavior and desires. While promoting the book, the journalist offered a psychological explanation for the flight attendant’s actions that, ironically, would very closely resemble the accusation of internalized homophobia that Shilts’s critics later leveled against him. “I think,” he opined, “that Gaetan was someone who had never accepted himself as a human being, hated the part of himself that was gay, hated other gay people, externalized that self-hatred, and became what in effect was a psychopathic killer.” Shilts went on to suggest the flight attendant’s universal importance: “Every city has its Gaetan Dugas.”⁵⁴ Removing all doubt about his impression of the flight attendant’s malice, the writer would later comment while on a U.K. book tour, “As a gay person myself I wasn’t thrilled about Gaetan’s behavior. I don’t see him as any more typical of a gay man than Jack the Ripper was of the heterosexual—but it did happen.”⁵⁵

In March 1986, one month after he had confirmed Dugas’s identity as “Patient Zero,” Shilts participated in an investigative journalism conference in Vancouver, a city where, he had learned, the flight attendant had resided. Speaking on a panel dealing with AIDS in the media, he appeared alongside Kevin Brown, a local AIDS activist. A remark about Dugas to Brown led Shilts to a number of Gaétan’s Vancouver friends within a twenty-four-hour period. These men shared with Shilts their memories of a charismatic and caring acquaintance, who had passed away two years previously in the spring of 1984. This sharing of information, one of these friends later noted, had transpired only after Shilts had promised not to reveal Dugas’s name in any publication.⁵⁶ From this group, Shilts gained the biographical information he needed to give personal color to the epidemiological picture he could already piece together from the medical literature. Two months later, Shilts would write to Marcus Conant to pass on the reference details for an article. “By the way,” he added proudly, “I’ve researched out Gaetan’s whole life story—Great stuff.”⁵⁷

Gaétan Dugas: Kaposi’s Sarcoma Patient and Book Villain

As Shilts discovered, Gaétan Dugas had been born in Quebec City in 1952. At the age of twenty he had traveled to Vancouver to learn English so that he could secure his dream job as a flight attendant. It was during this first trip to the West Coast of North America that Dugas met Ray Redford and the two had become lovers; their relationship lasted for a couple of years until the strains of Dugas’s frequent traveling and parallel romances overwhelmed it. After starting work for Air Canada in 1974, Dugas moved frequently between Halifax, Toronto, Montreal, and Vancouver, enjoying a very sexually active lifestyle with several hundred partners each year. Of particular interest to Shilts, Dugas had enjoyed spending time in New York and San Francisco, cities with early presenting cases of AIDS. He had been diagnosed with KS in 1980, and had eventually made his way to New York for treatment. As information emerged about “gay cancer” and AIDS over the next few years, he became very well acquainted with the medical literature. With an awareness of the limits of contemporary knowledge about the condition, Dugas was one of many gay men of the time who viewed medical claims and advice with skepticism. Nonetheless, he had been very helpful with researchers from the CDC, providing them in 1982 with the best early set of records for contact tracing they could find—seventy-two names of his previous sexual contacts.⁵⁸ As mentioned previously, this assistance would later garner him a central position in their cluster diagram, and, via Shilts, posthumous notoriety. After living in Vancouver for most of 1983, he became sick and returned home to Quebec City, where he spent his remaining days with his family until his death in March 1984.

The term “Patient Zero” might easily signify the complete nullification of a Gaétan Dugas’s “patient’s view.” Attending to his experience of sickness and struggle during the first years of the recognized AIDS epidemic from a variety of perspectives adds far more complexity—and humanity—to the character one encounters in Shilts’s book. Several points are worth emphasizing. First, he had received a cancer diagnosis in 1980, months before KS was linked to the newly emergent syndrome that weakened patients’ immune systems. According to a former colleague, he had steeled himself for a recovery from lymph node and skin cancer.⁵⁹ After months of thinking of himself as a cancer patient, it seems plausible that he would have viewed with skepticism attempts to link his illness to cases of pneumonia and other infections affecting gay men. Accordingly, in 1982, as someone who had lived with cancer for several years, he would not necessarily have viewed his lesions as significantly more disturbing than a complexion-marring sign of a noninfectious cancer. Of course, this would be in dramatic contrast to increasing numbers of homosexual men in New York and San Francisco, where efforts to raise awareness about the new syndrome often emphasized the risks of sleeping with someone with KS. As such, during the fear-filled months of late 1982, a strong possibility existed for encounters of almost complete incommensurability. If there is any truth to the rumors that Dugas would refer dispassionately to his lesions as the so-called gay cancer in postcoital conversations with bathhouse partners, it may be that his skepticism about his cancer’s infectiousness afforded him a calmness as he described a bodily condition to which he had grown accustomed.⁶⁰ In turn, some of his partners, and others—like Conant, Friedman-Kien, and Dritz, hearing accounts of these interactions—who were convinced of the transmissibility of a causative agent, interpreted this calmness as the cold-blooded malice of an individual intent on spreading his infection. In such a reading, the sense of deception felt by the latter group would only have been compounded by the fact that the codes of gay bathhouse cruising discouraged significant conversation before sex.⁶¹

Second, the absence of an agreed-upon cause of AIDS or mode of transmission at this time—especially before the CDC published inter-agency guidelines in March 1983 that explicitly compared the distribution of AIDS cases to hepatitis B infection—complicates this picture of intentional infection.⁶² Dritz herself admitted that when she confronted Dugas with the demand that he stop having sex, it involved stretching the available evidence. “I told him, ‘Look, we’ve got proof now.’ I didn’t tell him how scientifically accurate the information was. It wasn’t inaccurate, but it wasn’t actually scientifically proven. I said, ‘We’ve got proof that you’ve been infecting these other people. You’ve got AIDS, you know. We know it’s transmissible now, because you’re transmitting it.’”⁶³ As Epstein indicates in Impure Science, the period from 1982 to 1983 generated both intense debate and strong criticism of scientists and biomedical researchers, and individual self-education was considered to be the best approach for many gay men.⁶⁴ In the single available piece of evidence written by Dugas himself, the letter that begins this article, the flight attendant lamented the difficulty of obtaining reliable information about the condition. We can hypothesize that by November 1982 he may have grown tired of individuals overstating their case. Having Dritz, a sixty-three-year-old female public health official, telling him that he needed to stop having sex because she claimed she had proof that he was spreading the causative agent might easily have brought to Dugas’s mind the words published by a fellow Toronto resident earlier that month. In the Body Politic, the left-leaning gay periodical, the gay activist Michael Lynch argued that “gays are once again allowing the medical profession to define, restrict, pathologize us. . . . The American Psychiatric Association may have given us all an instant cure in 1974 when they took ‘homosexuality’ off the list of mental diseases, but now the MDs of the land have placed us on their agenda, and no one, so far, seems to be resisting them.”⁶⁵ It is unnecessary to invoke “sociopathy” to understand why Dugas continued to have sex in November 1982 and angrily resisted Dritz’s demands that he stop. Rather, tumultuous shifts in medical knowledge and political suspicions of anyone appearing to moralize against homosexual behavior might provide sufficient explanation. This tense period would shortly give rise to the politically defiant act of “safe sex” as articulated through the work of Joseph Sonnabend, Michael Callen, and Richard Berkowitz.⁶⁶ Dugas’s lack of compliance with calls that he abstain from sex, then, can be seen as part of a wider reaction, at the crest of a wave of change in disease prevention and sexual ethics in the gay communities of North America.⁶⁷

Third, it is very difficult to determine whether the intense discrimination Dugas faced in San Francisco and later in Vancouver was a result of any censorious behavior on his part, since he also appears to have endured fierce discrimination because his skin displayed highly visible signs of an increasingly feared condition. In 1983, when so little information had been disseminated locally about AIDS and Dugas represented the first person with KS most gay Vancouverites met, the flight attendant endured significant fear and resentment in that city. Ray Redford related that Dugas would continue to go out publicly, “despite being harassed by others at the bars and told that he should stay home.”⁶⁸ In an anecdote Shilts did not use, Kevin Brown related to the journalist how another of Dugas’s friends, seen walking with the flight attendant along Vancouver’s water-front, was later approached by a stranger and told, “Y[ou] sh[ould]n’t be seen w[ith] t[ha]t man. Y[ou’]r[e] g[oin]g to ruin y[ou]r reputation [/] he has AIDS.”⁶⁹ Still another friend, Bob Tivey, related in a 2008 interview that when he and Dugas had “gone out just to have a social drink” at Neighbours, a Vancouver gay bar, patrons moved across the establishment to distance themselves from the flight attendant. “I thought it took a lot of courage,” Tivey noted of Dugas’s appearances in public. “People knew who he was by this time, and they were afraid of him, people were afraid, they just got out of his way. These were other gay men moving when they saw him coming.”⁷⁰

Noah Stewart, a founding volunteer for AIDS Vancouver, a local community-based organization, made use of the flight attendant’s unusually long (for that time) experience of living with AIDS by asking Dugas questions about how he had dealt with various disease-related issues. Stewart described some of the paranoia of the time in an interview:

. . . but swirling with rumors? Absolutely, that Gaétan was lurking in Stanley Park infecting people, uh, that Gaétan was disguising himself, . . . that Gaétan was teaching people how to disguise themselves, . . . ridiculous things, just, idle gay gossip essentially and . . . I don’t think I heard any more, any of these things more than once from any individual, it was just really idle, it was a bunch of scared people making up stories. And I think even they realized it.⁷¹

Furthermore, evidence suggests that Dugas eventually came to subscribe to the main alternate theory circulating among men with AIDS—the “immune overload” or “multifactorial” theory. This framework—advanced by Joseph Sonnabend, a New York–based infectious diseases specialist, among others—held that repeated exposure to viruses, infections, sperm, and recreational drugs could bring about the collapse of the immune system.⁷² Coexisting alongside the idea of a new virus for some time, the overload theory held appeal for many since it suggested that one could derive health benefits from reducing the number of one’s sexual partners, rather than completely refraining from sex. It was thought that this might help reduce one’s continuous exposure to harmful agents that might further weaken the immune system. According to Noah Stewart, whom Shilts did not interview, the flight attendant substantially reduced his number of sexual partners while living in Vancouver.⁷³ In a letter sent to a local gay newspaper shortly after Dugas’s death, Stewart wrote of “a friend of mine [who] died recently of AIDS.” This friend, whom Stewart did not name “to preserve his anonymity,” had viewed the rumors surrounding him—which suggested that “he had been doing all sorts of things to deliberately communicate his disease to the uninformed”—as the “projection of the fears of the gay community.” Stewart noted that his friend had more to lose from casual contacts than did other individuals with healthy immune systems. “Since my friend had come to this realization, he had stopped having sexual contacts.” Describing his friend as “a symbol of the strength that people can find within themselves to meet extraordinary challenges,” Stewart explained how his friend had changed his habits and adapted his behavior, and had “fought the ignorance and fear of the people around him, meeting it with good sense and information.”⁷⁴

Dugas’s friends in Vancouver were horrified by the manner in which the journalist used their information for his book, identifying the flight attendant by name and stripping him of his likeable qualities. They were also dismayed by the media publicity that accompanied the book’s release.⁷⁵ Worried that the mainstream media might not give coverage to Shilts’s popular history, his editor at St. Martin’s Press, Michael Denneny, approved a bold publicity strategy. He focused on Shilts’s identification of Dugas as “Patient Zero” and the flight attendant’s conflicts with physicians and public health officials, sensing that the salacious story the journalist had created would prove irresistible. His hunch was accurate: the New York Post’s headline on October 6, 1987, epitomized the media’s response and characterized the popular memory of Gaétan Dugas from that point on. “the man who gave us aids” read the front page, claiming that Dugas “triggered ‘gay cancer’ epidemic in U.S.”⁷⁶ Other publications drew upon the frequently rehearsed narrative of a disease introduced from abroad by a foreigner. “Canadian Said to Have Had Key Role in Spread of AIDS,” wrote the New York Times, while the National Review nicknamed Dugas “the Columbus of AIDS.”⁷⁷ Several Canadian newspapers like the Toronto Star adopted a more cautious tone, suggesting that “MDs doubt claim Canadian carried AIDS to continent.”⁷⁸

Shilts’s extensive collection of papers, stored in the San Francisco Public Library’s archives, yields insight into the journalist’s writing practices. First, he would handwrite his interview notes, scribbling energetically on a yellow pad of lined legal paper, as he led his interviewees chronologically through the events he was interested in covering. Then, often the same night, he would type up his fragmentary notes into rough story drafts on his word processor, trying to reproduce his interviewees’ idiomatic phrases. Much of the book’s final manuscript can be matched up, often to the word, to the hundreds of pages of interview notes preserved in the archives.⁷⁹

Many of Dugas’s friends in Vancouver who shared their memories with Shilts would, however, be more concerned by the notes that were omitted from the book. Bob Tivey, for example, had agreed to speak with Shilts to describe what it had been like to be friends with one of the first people with AIDS in Vancouver.⁸⁰ Shilts’s notes reveal that Tivey had described a light-hearted day when Dugas had invited him for a picnic. They drove on Dugas’s motorcycle to a nearby town where they spent the afternoon walking around, eating, and drinking from little airplane bottles of champagne. It was apparent to Tivey how much isolation Dugas faced within the gay community when, at the end of the day, Dugas dropped him off and gave him a kiss, saying, “T[han]k you for g[i]v[in]g me a normal day.”⁸¹ In writing the book, Shilts skipped over this anecdote in favor of one that reinforced the image of Dugas angrily countering medical cautions to refrain from sex completely.⁸²

Kevin Brown, Shilts’s copanelist at the Vancouver conference, also shared a story with Shilts that did not survive the final edits. Brown told Shilts that he and Dugas had gone on a date to a beautiful restaurant set in Vancouver’s urban Stanley Park. When Brown admitted that he was interested in Dugas sexually, Gaétan hesitated before answering, “We can’t. . . . It won’t work out. I can’t say any more.”⁸³ This page-long section, completely written up and included in an early draft, was cut. While this may have been to tighten the pace of a long book, its absence removed any ambiguity from Dugas’s motivations, and strengthened the image of the flight attendant as a deliberate disease spreader.

Surprisingly, the published characterization of Dugas could have been worse. Those who were shocked to read the lurid description of him selecting a sexual partner in a San Francisco bathhouse might have been appalled to learn that this episode had been reduced from its original length. An extended version in an earlier draft bears the mark of a reviewer’s intervention, “Gaetan surveyed the material and made his choice. He edged into the small cubicle and waited for the ritual nod that indicated he would be welcome. Without speaking a word, the assignation was set and Dugas pushed the door shut. Gaetan could barely restrain a giggle as the thought once again arched across his mind and a certain glint crossed his mischievous eyes. Maybe he would play his little joke with this one .”⁸⁴ Evidently Shilts imagined that Dugas was “playing his little joke” and laughing at a mischievous idea—apparently the thought of infecting an unsuspecting partner.

By 1987, following a significant amount of local organization in response to AIDS, the gay community’s reaction in Vancouver to Band and the media circus surrounding the book’s treatment of Dugas was largely disapproving. “A lot of people who live here knew Gaetan,” Bob Tivey noted, “and I’m sure they’re feeling very hurt now because of all that’s been thrown at him.”⁸⁵ Tivey’s comments echo those of others I have interviewed, who commented that Dugas’s sexual behavior was not unusual for his era, and that singling him out represents an unfair retrospective judgment. Articles in the local gay newspapers at the time contested Shilts’s image of Dugas by emphasizing the fact that as one of the first AIDS patients in the province, he had been a vital resource of information for later persons with AIDS.⁸⁶ Others have pointed out that, while living in Vancouver, Dugas had reduced his sexual contacts and had even contributed to the support efforts of the local community-based AIDS organization.⁸⁷ When Shilts chose to cast Dugas as a specific character type, and focused his attention on the flight attendant’s activities during a narrow chronological period, the author significantly shaped the flight attendant’s public legacy as one of the most demonized patients in history.

Shilts’s characterization of Dugas was constrained by the journalist’s selective use of knowledge about HIV incubation rates, dramaturgic decisions, and the narrow timescale of his inquiry. The hardworking journalist was very effective in drawing on an international network of contacts to bypass the barriers that public health officials had erected to protect the identities of those men who had been linked through an earlier sexual network. Yet he used the ample information gathered in a highly selective manner. Shilts accepted little grayness in his interpretation of individuals’ actions in the early years of the epidemic. In 1987, as his book was appearing on national best seller lists, the journalist gave an interview to his hometown newspaper that offers insight into his frame of reference. Defining himself as a “straightforward” midwesterner with a journalist’s “basic open-mindedness,” Shilts explained to Aurora’s Beacon-News, “I believe in moral absolutes. To me, what is morally wrong is not being kind to your fellow man and ignoring situations in which you can help out.”⁸⁸ While in this instance the reporter was speaking of his deeply felt sense of injustice at the feeble federal response to the epidemic, his comments illuminate the black-and-white depiction he constructed of Dugas’s actions in 1982 and 1983. Animating his deeply moving history of AIDS, Shilts’s retelling of the “Patient Zero” story would captivate readers and take on a new dimension in an unfolding discussion about criminal penalties for the transmission of HIV.

“Not Just a Hypothetical Case”

And the Band Played On was published in a year that proved to be pivotal in the emergence of a discourse advocating for the use of criminal law to address HIV transmission. A front-page New York Times article from June 1987 noted a number of recent cases, particularly in the military, where individuals stood accused of willfully exposing other persons to the virus. The article emphasized that, although several of these cases related to instances of spitting or biting—modes that had not been demonstrated to pose a risk for transmission—these examples still contributed to an effort to rework the public health statutes in some states, to the opposition of many public health officials and gay-rights activists. They feared that politicians had seized upon “a handful of peculiar and frivolous cases” to justify action that would lead to a negative effect on public health: it could make those most at risk for HIV infection reluctant to get tested.⁸⁹ Attention to this issue continued throughout the summer of 1987, with Time magazine and the Los Angeles Times, among others, featuring articles and polls on the topic.⁹⁰ In a syndicated newspaper column, a professor of public policy noted the sharp contrast with the previous year, which had been, he thought, guided by robust scientific research. In 1987, however, “the Year of the AIDS Politician,” “sideshow” efforts intent on scapegoating led to calls for widespread mandatory testing, quarantine of people with HIV, and “new criminal penalties for that almost-mythical character, the deliberate spreader of disease.”⁹¹

These developments played into the Reagan administration’s slow-to-develop and socially conservative response to the epidemic. Jennifer Brier has argued that the most important factor shaping the Republican administration’s response to AIDS was the lead role taken by members of the Department of Education. The department’s secretary, William Bennett, and the under secretary, Gary Bauer, who was also Reagan’s advisor on domestic policy issues, developed a response that was in keeping with the religious support base of the New Right. Their approach took every opportunity to reinforce the supremacy of heterosexual marriage and traditional gender roles.⁹² To the notion of the “innocent victim” of AIDS—the HIV-infected blood transfusion recipient, for example—Bennett and Bauer set up a rhetorical counterpoint, the deserving person with AIDS. This idea was articulated in the writing of John Klenk, one of Bauer’s former aides: “The most common cause of the spread of AIDS is irresponsible sexual behavior. Anyone who engages in such behavior endangers him (her) self, his (her) partner, his (her) children, and other innocent victims—not to speak of causing enormous medical costs to taxpayers and the public. Society must show its disapproval for such behavior.”⁹³

It appears that part of Klenk’s remit was to assemble documented cases of alleged deliberate transmission. In June 1987, he sent a note to Bauer that listed a compendium of “thirteen ‘horror stories’—cases of malicious or irresponsible behavior threatening the spread of AIDS.” These included an Army private “who knew he was infected yet had unprotected sex with three soldiers (both sexes), one of them his fiancee”; a man with “full-blown AIDS” who raped a South Carolinian woman; a young Californian man who “boasted he’d infect as many coeds as he could”; men who bit police officers; a “parolee who announced he intended to infect as many prostitutes as possible, ‘just to get even’”; and a “civil rights activist who threatened ‘blood terrorism’ if enough money wasn’t provided for AIDS research.”⁹⁴ Bauer would have been able to add these cases to examples already in his files, of prostitutes allegedly returning to work after a diagnosis, and sworn testimony that apparently proved that “there are persons who are knowingly and intentionally spreading the disease. There exists a population of persons who have been infected and have the misguided opinion that the only means by which this disease will be cured is if it becomes so widespread that the government has to cure it. Their goal is to continue spreading it as fast as individually possible to reach that end.”⁹⁵

Also among Gary Bauer’s archived files is a copy of the October 1987 cover story of California magazine: the serialized “Patient Zero” story sold by Shilts’s editor as part of the book’s wildly successful promotional campaign.⁹⁶ As I have suggested, the publicity efforts of St. Martin’s Press were enormously effective in capturing the media’s attention. The timing ensured that the figure of the deliberate, malicious AIDS spreader, which had been forming in a somewhat inchoate manner earlier in 1987, and which built upon previously existing fears of people with AIDS, took root in the public imagination. Significantly, this figure now had a name and, following a 60 Minutes television news special in November 1987, a nationally broadcast face (see Figure 3).⁹⁷ It became possible to refer to Dugas’s example as shorthand for the type of criminally irresponsible person from whom the public needed protection. In addition, this historical case gave lawyers a powerful example of a malicious disease spreader that allowed them to circumvent the difficulties that they would have faced in terms of establishing malice and an intent to infect in a court of law.

Indeed, Dugas’s example was adopted in legal texts with remarkable speed. By November 1987, the same month that the book went into wide release, advocates of tough penalties for HIV transmission were mobilizing the “Patient Zero” story. The State Factor, a conservative legal publication put out by the American Legislative Exchange Council lobby group, featured Dugas’s interaction with Selma Dritz in its December issue. The article argued that criminal laws were needed to deal with this small minority of AIDS patients who “either are intent on infecting others—or simply do not care enough to change their sexual practices.”⁹⁸

In this period, legal scholars arguing for tougher sanctions often used the Dugas story to strengthen their case. In 1989, one author cited Shilts’s work repeatedly and focused on the author’s description of Dugas. There was some doubt, the author admitted, about whether Dugas was the first to bring HIV to the United States. “But there is no debate as to Gaetan’s conduct right up to the moment of his death. He continued to have multiple and random sexual partners, living a code of conduct that held: ‘It’s my right to do what I want to do with my own body.’” The author continued that it was “this type of intentional and reckless activity” that led to the Presidential Commission’s recommendation that states adopt criminal laws to regulate the reckless behavior of individuals.⁹⁹

Figure 3.

Gaétan Dugas becomes the face of AIDS as “Patient Zero” on the CBS television program 60 Minutes, November 15, 1987, presented by Harry Reasoner. Image reproduced with permission from BBC Worldwide Americas Inc.

Even those who opposed the criminalization of HIV transmission felt it necessary to engage with Dugas’s example. Kathleen Sullivan and Martha Field, two Harvard law professors who in early 1988 argued against the implementation of criminal penalties, conceded that

the AIDS victim who deliberately exposes others in order to gain revenge, for example, is no less culpable than a person who deliberately injects a victim with a lethal poison in the hope of causing death. Nor is culpability doubtful in other instances that are likely to count as murder under the Model Penal Code: for example, the prostitute who knows he or she is contagious and nonetheless plies his or her trade without precautions, indifferent to the number of persons thus fatally infected, or the person who, knowing he has AIDS, rapes another and so eventually causes his or her death.

In a footnote to document the existence of those attempting to spread the disease out of revenge, the authors noted that “the example of Gaetan Dugas . . . suggests this is not just a hypothetical case.”¹⁰⁰

This material found its way to the Presidential Commission on the Human Immunodeficiency Virus that President Reagan had assembled in the summer of 1987. The commission held its first hearings in September, just as the prerelease publicity for Shilts’s book began to take hold in the national media, and continued its deliberations until June 1988, during which time the book became a nonfiction bestseller. One legal scholar has intimated, albeit on scant evidence, that the temporal overlap of the release of Band and the commission’s hearings demonstrates that the book had an impact on the commission’s recommendations, which proved influential in legitimizing the subsequent use of criminalization as an appropriate response to the epidemic.¹⁰¹ This assertion is valid, but requires a more careful consideration of the evidence.

There were several instances where the story had the potential to influence the commission’s work. First, commissioners were mindful of anecdotes that they heard outside of the documented hearings. For example, in their discussion of the legal implications of HIV transmission in April 1988, Admiral Watkins, the commission’s chairman, emphasized the importance of “answering the question that’s so often asked me after many of these hearings.”¹⁰² In this instance he was contemplating the need for mandatory HIV testing for rapists in criminal cases, providing recommendations that might do “a lot to allay public fears, even though those circumstances in which the HIV may be transmitted by that means may be small.”¹⁰³ Thus, although it was apparently uncommon, the possible threat posed by a small group of individuals was emphasized and, unsurprisingly, the undocumented concerns of citizens from outside of the commission were imported into its deliberations.

Second, witness testimony and the commissioners’ discussions reveal a sense of urgency in dealing with the possibility of dangerous disease spreaders. One witness before the commission, a prosecutor from Genesee County, Michigan, had attempted unsuccessfully to prosecute an individual with HIV for attempted murder for spitting at a police officer. This prosecutor urged the commission not to be deterred from making strong recommendations in favor of criminalizing the transmission of HIV, in spite of a perhaps inconvenient lack of evidence. “It should be stressed,” he acknowledged, “that the percentage of AIDS carriers who will maliciously or irresponsibly place others at risk is largely speculative.” Nonetheless, he continued immediately, “This fact should not deter us from developing a legislative framework to control such conduct.”¹⁰⁴

Most compellingly, the language used by one commissioner demonstrated the way in which the term “patient zero,” originally coined as an epidemiological term to denote the Los Angeles cluster study’s nonresident case of KS, had evolved over only a few months of widespread public discussion to become synonymous with Shilts’s portrayal of Dugas as the dangerous disease spreader. Dr. Theresa Crenshaw, a sex therapist and one of the commission’s more socially conservative members, presented a justification for focusing on a small number of dangerous individuals. She had recently read that 5 percent of the “carriers,” for sexually transmitted diseases other than AIDS, were responsible for 80 percent of the cases. This meant, she reasoned, “that a very sexually active small group has an enormous impact on our society.” She continued, employing a telling choice of words: “We’re hearing such emphasis on the rarity of the patient zero or some of the individuals that you’ve alluded to, that have been prosecuted, whether they’re rare or whether they’re not rare we really must act promptly and effectively to prevent many others from becoming infected as a result of antisocial behavior.”¹⁰⁵

The commissioners were evidently concerned with the potential risk posed by individuals like Shilts’s “Patient Zero.” Their final report contained a separate section on criminalization in which the commission encouraged “continued state efforts to explore the use of the criminal law in the face of this epidemic.”¹⁰⁶ Source material from the commission’s support staff indicates that this section was based “almost verbatim” on Sullivan and Field’s article.¹⁰⁷ Notably, however, the final report’s criminalization section disregarded Sullivan and Field’s conclusion that “any deterrence that criminal enactments might add to incentives that already exist is not worth the disadvantages of using the criminal law as a tool to contain the AIDS epidemic.”¹⁰⁸ Though the final report cautioned that “the use of criminal sanctions should not substitute for use of public health measures to prevent transmission,” it seems likely that its recommendations for increased use of criminal law and the powerful stories of deliberate disease spreading typified by the example of Dugas may have contributed to just this type of trend.¹⁰⁹ Between 1987 and 1989, twenty states enacted statutes that sought to criminalize the knowing transmission of HIV.¹¹⁰

In 1990, the U.S. Congress passed the Ryan White Comprehensive AIDS Resources Emergency Act, which incorporated many of the Presidential Commission’s recommendations, to direct relief to the areas of the country most affected by HIV. Among its many provisions, the act required that states have in place “adequate” criminal laws to address the threat of intentional HIV transmission in order to receive federal grants.¹¹¹ By the end of the 1990s most states had in their statutes some form of legislation that addressed the deliberate transmission of HIV—an often feared, though seldom demonstrated phenomenon. This controversial approach was subsequently transferred internationally to several west African countries, through the process of “model HIV law,” where ready-made legal frameworks were exported abroad as part of U.S.-funded development aid. This process has been linked as an important factor in recent efforts to further criminalize the transmission of HIV.¹¹² Thus, not far below the surface of contemporary global HIV politics lurks the legacy of Randy Shilts’s depiction of Gaétan Dugas.

Conclusion

The meeting minutes of AIDS Vancouver’s board reveal two small but important historical moments that Randy Shilts did not uncover in his research. At their meeting on June 20, 1983, board members decided to send a representative to visit “G., an AIDS victim” who had recently been “seen in circulation.” The committee members hoped to appeal “to G.’s personal sense of responsibility to the community,” and “attempt to involve him productively in the fight against AIDS.”¹¹³ As noted in the preceding pages, it seems that they achieved the results they desired. Six weeks later, the meeting minutes capture a significant shift in terminology. “Bob [Tivey, Gaétan Dugas’s friend and the group’s support coordinator] noted that ‘people with AIDS’ is the preferred term over ‘victim’ or ‘patient.’”¹¹⁴ The recently announced Denver Principles were changing the landscape of AIDS activism and service provision, giving new voice to those living with and fighting the syndrome as well as the challenges it brought. These historical moments highlight how the environment of AIDS research and activism was under continuous change and evolution between 1981 and 1983, as were the sexual attitudes and behaviors of many, including those of Gaétan Dugas. In his book Shilts wished for Dugas’s character to represent those who refused to modify their ways; it is important that readers do not mistake this character for the living man, and sometimes patient, who did change during this period.

Now at a distance of over twenty-five years, it is clear that Shilts’s account of the early stages of the North American AIDS epidemic needs to be approached with care and placed in its own historical context. Any fair assessment must credit the journalist’s intense commitment to rendering visible the sickness and deaths of many, as well as his success at enlivening with vivid firsthand testimony the systemwide struggles brought on by the epidemic. Yet at the same time, readers must remain aware of the limits of his “straightforward” journalistic lens and the historical umbrae and penumbrae of its field of view. So too must we remember the fractured, balkanized terrain of knowledge in the earliest years of the epidemic and how this would have been experienced by the first sick individuals and the worried well. By what measures and at what historical points can one mark the establishment of a new paradigm of medical knowledge and a linked set of socially accepted behaviors? When we revisit Dugas’s life and conflicts with medical authorities, and consider the evidence from interviews with those who knew him, the label of “sociopath” becomes increasingly implausible. As a young, sexually attractive patient, Dugas had to deal with the rapidly changing state of his health, which radically altered his abilities to engage socially in the gay communities through which he traveled. In addition, he endured wild speculation about his activities amid a constantly shifting landscape of medical knowledge. The fact that he did make changes to his behavior—indeed, that his assistance helped guide some of the early efforts of Vancouver’s first AIDS organization—shows that there was much more to Gaétan Dugas than Shilts and St. Martin’s Press saw fit to print, and much more complexity to his experience than large swaths of the North American reading public cared to know.

This particular instance of the construction of a historical villain raises additional questions. How did the narrowly cast story spun by Shilts get reproduced so readily in other historical accounts? Much in the same way that the journalist’s portrayal of Dugas was swept up by legal writers and haunted the proceedings of Reagan’s Presidential Commission, have historians writing on AIDS unwittingly reproduced the timeless figure of the deliberate disease spreader? When Grmek included Dugas’s example in his History of AIDS, he observed that “every historian of disease knows that such an attitude of vengeance, or at least of recklessness, had contributed in other times to the spread of tuberculosis and syphilis.”¹¹⁵ Having undertaken this research, I suspect that it is the suspicion of vengeful transmission that has routinely accompanied epidemics in the past. In 1527 Martin Luther described horrifying stories he had heard of individuals attempting to spread the plague deliberately. “I do not know if I am to believe it,” the theologian wrote, expressing his uncertainty about these twice-told tales. “If it is true, then I do not know if we Germans are men or devils, it is true that there are exceedingly wicked people, and the devil is not slow to make use of them.”¹¹⁶ Dismissing as sociopathic the challenging behavior of individuals in the recent past seems akin to invoking the devil. A far more productive approach, it seems, would be for historians to continue in their attempts to understand the complexity of the past worlds in which patients formed, held, and adapted their views.