Patient Zero and the Making of the AIDS Epidemic by Richard A. McKay (review)

Randy Shilts’s And the Band Played On (1987), the first history of the AIDS epidemic, introduced the American public to Gaëtan Dugas, the infamous Patient Zero, who supposedly seeded the U.S. epidemic from coast to coast and, worse, may have been the vector who imported AIDS to North America. Most dramatically, influenced by several medical sources, Shilts portrayed Dugas, an Air Canada steward, as a psychopathic carrier who purposely infected other gay men. Shilts’s account was rapidly amplified by the popular media so that Dugas became for several years the human face of the epidemic in North America.

As Richard McKay demonstrates in his meticulously researched book, much of what we know of Dugas is a fiction, the transformation of an early AIDS patient into a demon. McKay’s project may in part be described as the biography of a false fact. Dugas, an exceedingly attractive young French Canadian with a highly active sex life in multiple cities, was diagnosed with Kaposi’s sarcoma (KS) in spring 1980, a year before the Centers for Disease Control and Prevention (CDC) published its first reports of pneumocystis carinii pneumonia (PCP) and KS in previously healthy gay men. He came to the attention of the CDC when it constructed a cluster study of early KS/PCP cases in Southern California, later extending it to ten U.S. cities. The CDC’s cluster consisted of the self-reported sexual contacts of the selected gay men. Erroneously assuming that the incubation period of this new disorder was approximately a year, the CDC inferred that the cluster demonstrated that AIDS was a transmissible disease and that infected individuals within the cluster, Dugas among them, had possibly passed the virus on seriatim. But the CDC provided no data plotting the temporal transmission of the disease from one man (with possibly scores of previous partners) to the next, so that the direction of supposed transmission remained obscure.

As McKay shows, Dugas’s importance within the cluster was unduly magnified in two unfortunate ways. While the other men in the study could identify only a few of their multiple partners, Dugas maintained an address book of his sexual contacts, information he shared with the CDC, ensuring that a higher proportion of the cluster’s members would be associated with him. Likewise, unlike most others, he could specify sexual partners on both coasts, boosting his image as a cross-country vector. In addition, while other cases were identified by city and sequence of diagnosis, Dugas, as the only outlier in the initial cluster of men living in Southern California, was tagged with the letter O, denoting “outside-of-California.” At some point, accidentally, the letter was transposed into the number zero, inadvertently marking him as the putative “ur-case.” Graphic displays of the cluster also distorted the data to Dugas’s detriment, presenting him (patient O) at the center of the network’s spokes, visually indicting him as the index case.

As McKay demonstrates, Shilts’s characterization of O as the demonic carrier, Patient Zero, required highly selective and biased research by this San Francisco Chronicle journalist. Why Shilts, himself gay, would choose to blame critical elements of the epidemic on a gay man is a subject that McKay analyzes in forensic detail, drawing from his assiduous archival work, interviews, and secondary sources. His two chapters on Shilts and Band offer an elegant and persuasive case for Shilts’s motives and the circumstances under which his ideas consciously and unconsciously formed. Shilts’s depiction of Dugas as a villainous Typhoid Mary was capitalized on by his editor, also gay, desperate to publicize a work that he feared reviewers and opinion makers were set to overlook. Once planted in the press, the Dugas story diffused rapidly through newspapers, magazines, and TV programs in the United States and Canada. (McKay, a Canadian, integrates his story into the parallel...