The New York Times - January 3, 1984
Lawrence K. Altman, M.D.

"I felt I was sure to get AIDS, sure I'd die from it," the young doctor recalls now. "Then I assured myself that I was not the first person to stick himself and that no one else has gotten AIDS that way. Still, when I had a cold or wasn't feeling well, it was in the back of my mind."

Another reassuring factor for him was the presence in the hospital of senior doctors who had dealt with every manner of infectious ailment and lived to tell the tale.

Doctors are supposed to ply their trade among the sick. And they are supposed to defend themselves from disease with the whole battery of effective, often simple weapons available to them. There is always a risk, of course, but a risk probably no greater than that faced by airline pilots or traffic police officers.

Yet AIDS is so relentlessly brutal that it has had a nefarious effect on the practice of medicine. According to some reports, there have been physicians and medical students - only a few, one is led to believe - who have become so frightened that they have refused to treat AIDS patients.

As I examined patients on rounds at Bellevue the other day, as I frequently have in the past, I thought about the issue. We are, after all, trained to deal with infectious diseases safely. AIDS is presumably infectious, conveyed, probably, by a virus. But it seems to require intimate contact and does not appear to be as contagious as many another dreadful disease - pneumonic plague, for example.

AIDS has even had at least one beneficial effect: It has forced more medical workers to pay appropriate attention to the often-ignored hospital infection control practices. Many doctors had not even been following the standard precaution of washing their hands after examining patients, despite all the teaching about the dangers to themselves and others of not doing so.

Those doctors, it seems, had forgotten the lessons of the past. Over the years hundreds of doctors and researchers have died from hepatitis, Lassa fever, or some other infection acquired as an occupational hazard at the bedside or in the laboratory. Some of these deaths have come from ignorance of the infection the physician was working with, others from lapses in technique.

Even when doctors and staff take proper precautions, rubber gloves cannot prevent the occasional accidents such as my young colleague's puncture wound. At Bellevue alone, at least 20 doctors have punctured themselves with needles contaminated in the care of AIDS patients, and all of them now go through their days uneasier than they were before. So far, none have come down with AIDS.

If, despite the odds, one of these physicians or others on the staff did come down with AIDS, he or she could inadvertently become a martyr to medicine, possibly offering the vehicle by which the cause of AIDS would be determined. As soon as staff members have such an accident they are supposed to report it - in fact some don't - so they can be constantly monitored through blood tests and questionnaires for any change. The course of the disease can thus be chronicled from its very inception.

At Bellevue there was evidence everywhere of the human cost of this terrible disease, of course, but evidence as well of the measures health workers have taken to protect themselves as they meet their responsibilities. In a broad sense, the visit offered an illustration of how medicine has always approached the scourges of mankind.

The number of AIDS cases at Bellevue fluctuates from day to day. On this particular day there were 15 confirmed and three suspect cases, fewer than the peak of about 30 last spring. Some patients had recently been admitted; others had been there for nine months. Their presence was indicated in the signs posted by the doors to their rooms, advising doctors and the staff to don masks, gloves or gowns as appropriate for each case before entering.

AIDS patients are affected by many opportunistic infections, caused by microorganisms that generally do not cause illness in people whose immune defenses are working normally. For that reason, the specific attire and precautions that the doctors take to protect themselves depend on the type of opportunistic infection involved, while they also protect patients with impaired immune systems from organisms the staff might carry, harmless to themselves but possibly deadly to the AIDS patients.

Inside the patient's room, a purple box labeled "deposit sharps" was additional evidence of the precautions. In it we deposit used needles, razor blades, and broken glassware used in the patient's care. The intention is to minimize accidental wounds or, perhaps, theft by an addict who would inadvertently be further contaminating himself. On the windowsill are bandages and other supplies that normally are kept in a central room on each floor. It becomes necessary to minimize the amount of walking around one has to do in caring for the terribly ill; you do not want to have to take off your gown to walk out into the hall for a bandage.

There were signs of life and even hope in these grim rooms. Christmas cards and other holiday tokens decorated the walls. Above the plants, there were postcards with pictures of Pope John Paul II and posters reading, "Lord, Let Your Face Shine on Me." There were visitors. But for some AIDS patients, the telephone and television sets by the bedside were the chief means of contact with the outside world.

Several patients were mere shadows of themselves. One who had been in the hospital since last April had lost 68 pounds. Another who looked wasted had told his doctors he was frightened because he knew he was dying. He died a day later.

As I walked through the rooms I was reminded of a friend who is a medical student. She is apprehensive about dealing with AIDS patients, although she realizes the fear is probably irrational. What she does, she told me, is take on a role as an actress does, never letting the patient see her fear. "It's not my place," she said, "to add to their burden."

What goes through the mind of a doctor examining patients with this or any other terrible contagious disease?

Like steeplejacks and soldiers, physicians are cautious as they act on their knowledge. They also rely on denial defenses in treating certain disorders. A similar denial defense comes in handy for crossing the street; after you have done it so often, you do not think about the infinitesimally small chance of being struck by a car. Those who believe such small risks are too great for them presumably do not apply to medical school.

My thoughts on these hospital rounds were much the same as when I examined other AIDS patients in New York, Atlanta and elsewhere, beginning when the disease was first recognized in 1980. I empathized with the patients more than I feared for myself. I thought how horrible it would be to trade places with these patients. I believe almost certainly that I have no reason to fear contracting the disease. Not only am I in none of the risk groups for AIDS, but I also know the epidemiological data. If AIDS were transmitted by droplets through the air like influenza is, or by casual contact as measles is, many doctors, hospital workers and family members would have caught it. But that has not happened.

My deepest concerns, in fact, were much the same as those of the public at large. Why can't we discover the cause of AIDS? Why can't we develop more effective therapies? I felt a kinship with physicians of another century, who, knowing far less than we do, must have been overcome by frustration as they walked among victims of the plague or yellow fever.

I was reminded of the days when I examined some of the earliest victims of legionnaires' disease in 1976. Even though the epidemiological facts were scanty at first, I was comforted by the data that suggested it was only rarely contagious. There had been no secondary spread from an infected person to a family member or friend. At the time, some nonphysicians who heard about what I had done wondered if perhaps I had gone beyond the limits of safety. I did not; I regarded it as a necessary part of my work. I was disturbed then by reports that some pathologists, like those few today who are paralyzed by fear of AIDS, would not do autopsies on legionnaires' disease cases.

What if my judgment is wrong? Don't doctors always have a little lingering apprehension about their contact with contagious diseases? What if the experts are wrong and it just takes a much longer time than anyone realizes to develop the disease?

These possibilities do not seem to worry me. I have a certain amount of confidence that if I act prudently, in concert with what is known about the means of transmission of each infectious disease, and take the precautions physicians learn through normal training, nothing will probably happen.

The Centers for Disease Control in Atlanta periodically issue guidelines for preventing the spread of infections in hospitals. For some cases of AIDS the guidelines are similar to those for hepatitis B, requiring gloves, careful hand-washing, labeling with a red sticker as potentially dangerous any samples of blood, urine, sputum and stool sent to the laboratory. In addition, the patient may require the drastic measure of isolation.

Of course, there can be a false sense of security in believing that all samples not labeled dangerous are safe. They may harbor dangerous organisms from patients whose infectious diseases have just not been recognized yet for what they are.

It is also a matter of the odds. Not everyone who is susceptible to a disease and exposed to it will become sick. And there is some fatalism involved. There is probably as much chance of getting some infections at school or on a subway or train as in the hospital. The viruses that cause influenza and chicken pox, for example, can be spread by infected people even before they develop symptoms.

There is comfort in knowing that even if one gets many bacterial diseases, they are treatable. But that is offset by the fact that there are few effective treatments against viral diseases.

Few doctors would deny that they have some fear of contagious diseases. But they are most afraid of being surprised, of finding out that a patient thought to be suffering one ailment was suffering another. A colleague who was not wearing any protective gear at the time he came in contact with the saliva from a patient in an African hospital, was shocked to learn the man had rabies. The physician spent several anxious months worrying if he, too, would fall victim. He did not.

Maybe the Bellevue doctor who stuck himself with the AIDS-contaminated needle put the risks in better perspective when he said, "I'm even more apprehensive about someone with drug-resistant tuberculosis who coughs in my face than I am about touching a patient with AIDS."

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