From: MPetrelis@aol.com Date: Wed, 1 Sep 1999 14:28:45 EDT Subject: CDC's Intelligence Arrives in San Francisco The CDC's Intelligence Arrives in San Francisco By Michael Petrelis Phone: 415-621-6267 Presented to the SF Health Commission August 31, 1999 I never thought a one-line warning from Bette Davis in "All About Eve" would give me perspective over an alleged syphilis outbreak among San Francisco gay men cruising AOL chatrooms, but it has. Davis advises guests at her party to "Buckle your seatbelts, it's going to be a bumpy night." She then proceeds to ensure the evening is funereal. My updating of that movie classic would cast Gwenn Hammer, PhD, in the title role and she could utter the immortal line, that would apply to the events in July 1999 leading up to an alert issued to health care providers and the media about syphilis among gays. Who's Hammer, anyway? The answer begins on July 29 when Dr. Jeff Klausner, director of the SF health department's sexually transmitted disease control branch, began distributing a one-page alert. "In the past four weeks, we have identified four cases of early syphilis among white gay male residents of SF who report meeting the majority of their sexual contacts through internet chat rooms," the statement claimed. It seemed strange Klausner was rushing this alert out to the press and public without offering an ounce of scientific proof to prove his assertions. As I perused gay city health chief Dr. Mitch Katz's report included in the minutes of the August 3 SF health commission meeting the following paragraph sharply caught my attention. "A Centers for Disease Control (CDC) Epidemic Intelligence Service (EIS) Officer Gwenn Hammer, PhD, has been assigned to the San Francisco STD program for a two year period, from July 1, 1999 to June 30, 2001. She is an epidemiology, occupational health and safety policy expert, who will be working with the STD, HIV and CD Sections on outbreak evaluation and response, and long term primary prevention studies." Hmmmm. Hammer arrived in town at the start of July and before the month was over, a syphilis alert had been declared. A mere coincidence? Probably. No need to get suspicious, but skepticism was certainly called for in wondering why the CDC would assign an EIS officer to San Francisco right before an outbreak. I was more intrigued by the Epidemic Intelligence Service reference, which brought to mind Cold War spy novels. In all of my years as an AIDS activist I had never come across the EIS acronym before. Every reporter and colleague I asked if they knew about this program said no. Except members of ACT UP/San Francisco, who knew about the EIS and had grave concerns. Klausner happily sent me a twelve page memorandum of understanding between him and Dr. Laura J. Fehrs, chief of the epidemiology program office of the EIS. Fehrs wrote that Hammer, among other duties, was responsible for sending monthly reports to her superiors, without any personal identifiers to better protect the confidentiality of ill persons Hammer was coming in contact with in the field. Convinced Hammer's July report would have substantial data about the syphilis cluster alert, I phoned Fehrs in Atlanta to request a copy. She declined to speak with me, but her aide told me to call Doug Hamilton, MD, director of the EIS. During a 30 minute telephone interview Hamilton gave me much background on the EIS training program within the CDC. "The EIS was established in 1951 as the eyes and ears of the CDC. EIS provides the opportunity for officers to learn practical applied epidemiology in a structured two-year program," he said. "Dr. Klausner, head of your STD control branch out there is an EIS graduate," Hamilton said. "In December, Dr. Klausner submitted a single page request for an EIS graduate to train with him. That request was shared with all members of last year's EIS class for their consideration. Obviously, Gwenn Hammer read and liked the proposal." But how and when did Klausner and Hammer meet to agree on her assignment to SF, I asked. "We hold a session in April at the CDC that's akin to a campus pledge week. Health officials from around the country travel to Atlanta to meet EIS graduates. This year's session is where Klausner met Hammer, and they must have liked each other because she is now in the field out there under Klausner's supervision. Hammer takes orders from Klausner, not the EIS back at CDC," explained Hamilton. In conclusion, Hamilton claimed Hammer's July monthly report "would be dry, technical and probably not have any data about the syphilis outbreak in it. You'll have to file a FOIA [Freedom of Information Act] request for that, anyway." He gave me the CDC's FOIA officer's name and phone number, I called her and await a reply. Hamilton mailed me an EIS promotional brochure touting the importance of EIS related to the discovery of AIDS in America. "In 1981, an EIS Office assigned to the Los Angeles county Department of Health Services was involved in the identification of the first cluster of cases of the acquired immune deficiency syndrome (AIDS)," the pamphlet notes. How is it the EIS has never come across my AIDS radar screen before? I found all this background fascinating, but it wasn't bringing me any closer to the definitive data I sought about the syphilis cases. Hammer phoned me last week to say Klausner was considering my request that he publicly present his data. She said she couldn't mail me any proof about the syphilis cases. While all of the news stories were circulating about the syphilis outbreak, I inquired again with the health commission about the three-month delay in releasing the comprehensive annual STD report for 1998. In the first week of June 1998 Klausner distributed the 1997 annual report on time. The HIV Prevention Planning Council (HPPC) asked Klausner at their August meeting when the new report would be ready. According to the minutes "Jeff responded that the annual report should be available in October of 1999." Note the use of the word "should." I won't be holding my breath Klausner will have the report available then. The importance of the annual STD report can't be overstated, in my opinion, because it is a feature length movie in terms of data collected, analyzed and then used to set public health policies. Versus a monthly STD report, equal to a snapshot really. Heck, the monthly STD reports always conspicuously features a bolded box with the proceeding caveat. "Note: All statistics are provisional until the annual report is released for the year." Unless, you have a syphilis outbreak and you need to shift resources and personnel away from preparing the annual report and instead focus on an alleged outbreak of syphilis, right? The problem with thinking the annual STD report is tardy because the health department was stretched thin handling the syphilis outbreak is that the report should have been available in June, a full month before the outbreak. What valid reason is there for delaying release of the annual report? This juncture seems an ideal spot to point out confusing policies seemingly at odds here. On one hand, the STD branch wants all monthly data to be "provisional" until they have had adequate time to evaluate it over the course of a calendar year. However, the STD officials on the other hand believe their new syphilis cluster data warrants breaking that "provisional" rule. Why bother loudly repeating the warning monthly only to ignore it at whim? And what is one to make of this epilogue from Sir Josiah Stamp cited at the very end of the annual summary for 1997, authorized by Klausner? Is Klausner the watchman putting down only what he wants to see? "The government [is] extremely fond of amassing great quantities of statistics. These are raised to the nth degree, the cube roots are extracted, and the results are arranged into elaborate and impressive displays. What must be kept ever in mind, however, is that in every case, the figures are first put down by a village watchman, and he puts down anything he damn well pleases." If the STD branch indeed can prove this gay cluster of syphilis cases was contracted from sex partners met over the Internet, it may demand extraordinary precautions and warnings be adhered to. But where is the scientific evidence that launched this never before seen type of STD warning? To further confuse the situation, the week after the syphilis alert was issued, results from a statistical model study were printed in a scientific journal, comparing unsafe oral sex against unsafe anal sex between gay males. The SF health department's AIDS Office, specifically Dr. Susan Buchbinder, designed the study. I called her assistant Paul O'Malley not to ask for a copy of the study, since it had been actually conducted years ago, but to request a copy of the protocol for a current similar study, Project Explore. This new multi-city cohort study is recruiting HIV negative gay men to compare different behavioral interventions and how well HIV prevention counseling works today. The protocol for Project Explore contained this nugget that sent my mouth south to the floor. "Syphilis is not included as an endpoint in this trial due to its current low prevalence among MSM [Men who have Sex with Men]. . . Tabet, S.; Krone, M.; Paradise, M.; et al. Herpes, the most common STD in a cohort of high-risk HIV negative men who have sex with men. Abstract, XI International Conference on AIDS, Vancouver, 1996." Needless to say, I had to read this citation in full, so I looked it up in Abstracts, Vol. 1, Vancouver, July 7 -12, 1996. It's on page 164, column one. This study researched gay men from the Seattle area, no year given. "The median age of the . . . participants was 32 years, and 85.9 percent were caucasian," the abstract reads. "Of 499 results available . . . four participants were seropositive to syphilis, of whom three had been previously tested." The four men with syphilis in this trial didn't register even as one percent when compared with how many had positive results for herpes. Even though this study was presented more than three years ago, it is the exclusive argument made to exclude syphilis testing from the Project Explore study, launched in 1999. If the researchers behind Project Explore wish to expand their trial to now include syphilis testing, because of the alleged outbreak, they will first have to convince the Institutional Review Board (IRB) overseeing the study, then also convince the Community Advisory Board (CAB) to revise the protocol. If that happens, I will insist both the IRB and CAB first hold public meetings to share their definitive data to amend the protocol and began testing participants for syphilis, at additional cost. We must require these boards show actual clinical proof this syphilis outbreak has been real and is the basis for syphilis testing during the course of Project Explore. Vague one-page alerts and hysterical advertisements from Klausner should not be considered valid scientific evidence. The primary reason why Project Explore is happening can best be summed up in a statement from Michael Ahearn, the Clinical Coordinator of the trial, in the April 29 Bay Area Reporter. Ahearn believes "this study is crucially important since Explore could provide a potent case for funding of more and enhanced prevention counseling." Gee, I bet just like the prevention we get in studies like Project Explore, right? Or do I get three guesses? The results of the study won't matter much in the end. The researchers and prevention workers will say the same three little words they always say after one of these studies hits the papers, "Use a condom." Or their other three favorite words:"Give us funding." Which brings me back to AIDS, the number one reason why we have all of these issues to confuse us. Practically every aspect of AIDS and gay sexuality in San Francisco is seen through a prism constructed in a crisis mentality no longer pertinent today. Yet, one fundamental building block in this makeshift crisis structure is the bathhouse issue and it incredibly can explain an enormous amount about what is wrong with our approaches to AIDS and STDs among gays in SF today. The draconian prohibition against private spaces for gay men in public bathhouses has been unconscionably maintained for fifteen years and was reaffirmed by Katz in a July 28 letter to the HPPC. "I appreciate that there is no definitive data to support or refute my position. It is not unusual in public health to lack definitive data," Katz again boasted. In other words, no science is no problem when designing policy related to gay sex. For fifteen years San Francisco has not been required to produce science to explain the bathhouse ban. The health department simply feels it would be best to deny gay men sexual privacy in public bathhouses. With that in mind is it any wonder I am highly skeptical of the alleged syphilis cluster? Certainly not. Under the framework of bogus argumentation for restricting the civil liberties and sexual expression of gay males, it is a sacred duty to demand full honest scientific proof a syphilis outbreak among gays may have occurred. Keep in mind, the day after Katz reminded the HPPC of his data deficiency, Klausner issued his first syphilis warning, perhaps also deficient in the data department. It doesn't take a master's degree in public health to theorize Katz's scientific and intellectual laziness may have found a match in Klausner and how he deals with gay sex. In the end, I think the bureaucrats ensconced within all branches of the SF health department, especially the gay ones, are incapable of even forming a cabal, never mind carry out some grand conspiracy to demonize gay sex. However, just stirring up fear about gay sex virtually guarantees funding flows from many sources and money drives the health department tank in this city. It also makes sense in a Keystone Kops clumsiness that a heterosexual, Klausner, would aid the gay bureaucrats and lead the syphilis scare. Finally, I plan to keep my seatbelt securely fastened during the remaining 22 months of EIS officer Hammer's tenure here. If her first two months in town are any indication of what to expect, it will be a barrage of conflicting statistics, ugly ads in the B.A.R., few facts, buckets of ink, further demonization of gay sexuality, increased HIV and STD prevention and testing dollars from the CDC, and a huge magnifying glass examining every orifice of any sexually active gay man in this town. It may be a bumpy two-year night for us under the EIS's prying eyes, but one day a new assertive gay skepticism will dawn. And health officials of all stripes won't know what hit 'em when it does. We also should have the definitive data by then, finally explaining this alleged syphilis cluster. --------------------------------------------------------------------------- From: MPetrelis@aol.com Date: Thu, 9 Sep 1999 13:14:47 EDT Subject: Re: CDC's Intelligence Arrives in San Francisco REPLY FROM MICHAEL AHERN AT S.F. DPH: Date: 99-09-08 15:14:13 EDT From: michael_ahern@dph.sf.ca.us To: mpetrelis@aol.com Michael: Changes in the Explore protocol since December, 1998 include a change in the age of eligibility from 18 down to 16. A minor change was made to the provisions we have for remote HIV-Ab testing: The test was changed from one brand to another. There are no changes in the protocol related to syphilis or syphilis testing at all. In San Francisco, participants can elect, at their option, to get a test for syphilis. This is a public health service and not part of the Explore study. Mike Ahern