Wall Street Journal - March 12, 1984
Marilyn Chase, Staff Reporter of The Wall Street Journal

What is unusual about the Kushnick case isn't that an AIDS victim was treated in death as a pariah. What is remarkable is that Sam was only three years old and belonged to none of the principal risk groups for the disease -- promiscuous homosexuals, Haitians and heroin addicts. The little Los Angeles boy was one of a small but growing number of AIDS casualties who contracted the disease after receiving blood. So far 70 AIDS victims -- 46 transfusion recipients and 24 hemophiliacs treated with plasma products -- appear to have blood ties to the mysterious epidemic.

AIDS is a fatal collapse of the human immune system. Without its built-in defenses to disease, the body eventually succumbs to certain rare cancers, pneumonia, or to other so-called "opportunistic infections." So far, AIDS has killed approximately 1,566 of its 3,646 victims, and doctors have no reason to expect anyone to survive the disease. In the cities in which AIDS is most prevalent -- New York, San Francisco, Los Angeles and Miami -- public-health officials add daily to their census of the dead and dying. Blood transfusions compound their problems.

Blood may be "the gift of life," as blood banks like to call it, but it also can be an agent of disease and death. Doctors now believe that some people in high-risk groups who have yet to exhibit AIDS symptoms may, like Typhoid Mary, carry disease and unknowingly pass it on via their blood. San Francisco has had two cases of what appears to be transfusion AIDS. But the blood of 12 of the city's AIDS patients, who had donated blood before they became sick, was given to 50 transfusion recipients. None of the 50 have yet developed symptoms of AIDS. But the possibilities are enough to make people panicky about transfusions.

"There has been such terror. A guy nearly bled to death before he accepted a transfusion," says Herbert Perkins, the scientific director of Irwin Memorial Blood Bank in San Francisco.

Blood is a billion-dollar enterprise, not to mention a precious and perishable commodity. Whole blood lasts only 32 days, so inventories need constant replenishing. Blood banks collect 12 million pints of blood a year from eight million donors. That blood goes to three million transfusion recipients during surgery, in cancer therapy, burn therapy and other treatments. About 98% of blood is recruited from volunteers who roll up their sleeves for a Lorna Doone and a thank you. The rest is bought, often from destitute people who sell blood for as little as $6 a pint.

Confronted with doubts about the purity of the nation's blood supply, blood-bank managers offer firm assurances. "We have a very safe and effective blood supply," says Alfred J. Katz, the executive director of the American Red Cross Blood Services, which supplies half of U. S. blood needs. But, he adds, "Blood is a medicine and, like any medicine, it has risks as well as benefits."

Some blood-bank managers insist that the evidence linking transfused blood to AIDS is circumstantial. And doctors all agree that contracting AIDS isn't something that can happen to donors as a result of giving blood. Still, last year, blood donations dropped an estimated 6% to 10% nationally, partly because of the unfounded fear that giving blood somehow puts one at risk, partly because people in high-risk groups had heeded official urgings that they refrain from giving blood.

Blood-donor forms now have a section that delicately discusses the sexual practices that might make one susceptible to AIDS or cause one perhaps to be a carrier. They ask Haitian immigrants and male homosexuals who have been promiscuous not to donate. Intravenous drug users, as always, are shunned as donors.

Health officials admit to having a sensitive problem here: They face a disease 70% of whose victims are male homosexuals, but their screening programs aren't foolproof and can't fairly discriminate against homosexuals at large. Flatly ruling out blood donations from an entire segment of society would be "defamatory," says Selma Dritz, San Francisco's assistant health director.

Calling the screening program a "voluntary deferral" of high-risk donors thus seems to sidestep any clash between public health and civil liberties. Harry Britt, a San Francisco city supervisor and a homosexual, says: "I'd resist any effort to exclude us categorically as donors," but he nevertheless regards the voluntary program as "intelligent policy."

But because it is voluntary, the system is imperfect. "Let me paint a picture for you," says one worried blood-bank manager. "Let's say you're gay, and your office is the target of a blood drive. The pressure is on. Your colleagues are saying 'Aw, come on. Do it for good old Fred.' What do you do? "

Blood banks in New York and Miami try to offset such pressure on the closet homosexual by providing a special telephone number to call if one has given blood and thinks the blood bank ought not to use it. New York Blood Center has added an enclosed booth where donors in privacy can check a box on donor forms indicating whether they regard their blood as safe for transfusion or "for research only." Despite such safeguards, officials worry.

"It's not going to be 100% effective; everyone knows that," says John Petricciani, the director of blood and blood products for the Food and Drug Administration's Bureau of Biologics. "At the same time, we're hopeful it will have an impact." Blood bankers argue that the drop in donors is a sign their efforts are working. But because of the long incubation period for AIDS, it may be some time before anyone knows how well "voluntary deferral" works. According to a Centers for Disease Control study of transfusion AIDS, reported in the New England Journal of Medicine, patients had their suspect blood transfusions 15 months to 57 months before they were diagnosed as having AIDS. The median time lag was 27.5 months.

Hemophiliacs may face an even greater risk than transfusion patients. To treat their uncontrolled bleeding, many use a clotting product derived from human plasma called Factor VIII. Plasma -- the clear, straw-colored liquid that remains after red cells are spun off from whole blood -- is mostly bought from commercial plasma centers. Health officials know that desperate poor people who will sell their blood for a meal or a bottle of booze are likelier to be sick than volunteers generally, if not with AIDS, with other transmissible diseases, including hepatitis and syphilis. Since plasma for Factor VIII is pooled with plasma from perhaps 1,000 sources, one or a few AIDS carriers could taint whole lots of Factor VIII.

Accordingly, the FDA has quietly negotiated a voluntary agreement with the four makers of Factor VIII -- including the Red Cross and Cutter Laboratories Inc. -- not to make any more Factor VIII from plasma purchased in major AIDS centers, such as New York and San Francisco.

What blood banks need is a specific test that would allow them to screen blood for AIDS as they now routinely screen it for syphilis and hepatitis-B. About $26 million in grant money has been made available by the National Institutes of Health for the study of links between transfusions and AIDS. But until researchers have isolated an AIDS virus or other causative agent, a specific blood test will have to wait, perhaps for years.

At least one blood bank isn't waiting. Since last June, the Stanford University Blood Bank in Palo Alto, Calif. has imposed a controversial test on the blood of its 20,000 annual donors.

"We already know the volunteer program doesn't work," asserts Edgar Engleman, the director of Stanford's blood bank. "We already had one donor slip through the system here," he says. "A gay man with multiple (sex) partners gave blood anyway and then called us up. He was concerned about his own immune system. He had given blood 15 times before."

The test Dr. Engleman uses is called a T-cell test. Simply described, it measures the body's general resistance to disease. Results show abnormality in 2% to 3% of the general population, and they may just reflect a recent infection of no consequence. But the beauty of the test, as Dr. Engleman sees it, is that it reveals weakened immunity in every AIDS patient on whom it has been used. It is sufficiently revealing that AIDS specialists now use T-cell test results to help them diagnose AIDS.

But the test has drawbacks, as Dr. Engleman admits. For one thing it requires a $250,000 cell-counting machine. Performing the test costs Stanford $15 per donor. And it causes the blood bank to discard 2% to 3% of donated blood, most of which probably is AIDS-free. That blood loss must then be replaced from other donors, entailing more blood drives and higher costs. Dr. Engleman has increased his charge to Stanford Hospital for a pint of blood to $66 from $60.

He thinks it is worth it. He cites the case of a 49-year-old woman who contracted transfusion AIDS after heart surgery. Hospitalized for AIDS before she died, she ran up a hospital bill (exclusive of doctors' fees) of $200,000. "For the price of that one admission, we can screen almost all our donors for one year," Dr. Engleman says. "The test isn't perfect, but it's better than no test."

The blood bankers disagree. Dr. Katz of the Red Cross calls Stanford's testing "an experiment, and not something that can be recommended for the entire country," because of its cost and because of the supply problems it would create.

Harsher critics accuse Stanford of trying to lure patients from other nearby hospitals by playing on their fears about AIDS. Joseph Bove, the director of the Yale-New Haven Hospital Blood Bank, says the test is "a marketing tool for a medical center," and as such it is "distasteful."

Dr. Engleman replies: "I'm not saying every blood bank in the country should use the test, just the cities with a high incidence of AIDS. " He has support from, among others, Paul Volberding, the chief oncologist at San Francisco General Hospital and the head of its AIDS ward. "Pressure is mounting on blood bankers to do something," he says. "And so far, the T-cell test seems best."

Other, less expensive tests are being evaluated as possible ways to screen blood. Because many AIDS patients have previously had hepatitis, some doctors believe that a procedure called the hepatitis-B anticore test might be useful. It costs $10 to $12 to perform, and it would eliminate 5% to 7% of all blood donors. A test called beta-2-microglobulin is said to show promise in predicting that a blood donor may go on to develop AIDS. This test costs $2 to $3 and would rule out 2% to 3% of all donors.

Blood banks, however, appear to be united in resisting the tests, arguing that the costs and the diminution of critically needed blood supplies that tests result in would be far worse for society than the plight of the 46 transfusion AIDS cases counted so far.

"It would mean supply problems all across the country if these tests were initiated," says Johanna Pindyck, the vice president of New York Blood Center. And she has reason to fear a shortage. The center normally collects 800,000 pints a year. At least in part because of the AIDS scare, its collections declined 11% in 1983.

"It's important to find a test that doesn't rule out too many donors," says Dr. Perkins of San Francisco's Irwin Memorial Blood Bank. "You'd risk far more lives if there isn't enough blood."

Dr. Amoz Chernoff, the director of the NIH Heart, Lung and Blood Institute, agrees. "The cost-benefit analysis of these tests doesn't justify our doing them," he says.

San Francisco General's AIDS epidemiologist, Andrew Moss, warns that, because of the long incubation period AIDS seems to have, screening tests aren't likely to identify symptomless carriers who have yet to be diagnosed themselves. And blood bankers insist that contracting a relatively rare disease through a transfusion isn't very likely. "More people are killed by bee stings" than by transfusion AIDS, says Yale's Dr. Bove.

One victim of the disease he is concerned about, however, is the blood banks. "We've worked so hard to build our blood-banking system, to get good press, to get a good image," he says. "I think that's now at stake."

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Dead at Three Years, Sam Kushnick

Got Transfusion From Suspect Donor

Little Sam Kushnick was just one of about three million transfusion recipients in the U. S. each year. So his death doesn't argue very loudly for a change in bloodbank policy, even though a transfusion seems to have cost him his life.

On the other hand, the costs and inventory problems blood banks have to cope with aren't very compelling to Jerrold and en Kushnick, Sam's parents, who are partners in a West Hollywood theatrical agency. Since their child's death, the4R "If we can't save another child, then Sam's life will have been a waste," Mr. Kushnick says.

In the summer of 1980, Mrs. Kushnick gave birth to premature twins -- Sam and Sara. The infants each weighed Center, where the babies were born, replace even small quantities of blood drawn for tests from infants so small. Thus, Sam and Sara both got many small transfusions. Sam had 20 transfusions involving blood from 13 different donors. One donor, according to a subsequent health-department search, was a promiscuous homosexual whose blood was given to Sam but not to Sara. The babies both did well until they were about two years oxDld, when Sam began to suffer recurrent infections and his growth seemed to stall. The illnesses seemed to be common childhood episodes of earaches, fever and flu. But, as Mr. Kushnick recalls, "He began to get lethargic. We knew something was wrong."

Last Sept. 25, Sam was rushed to the hospital with pneumonia. A lung biopsy confirmed that it was pneumocystis carinii, a rare strain but common in AIDS patients. On Oct. 12, Sam died.

Cedars-Sinai and its lawyers have declined to comment in any way on the Kushnick child's death. The parents say that hospital officials attempted to block their efforts to bring in an AIDS specialist from San Francisco. They were able to bring the doctor in only by "swearing he was a family friend," Mr. Kushnick says. He says, furthermore, that the hospital at first refused to list AIDS as the official cause of the child's death.

The Kushnicks then had to contend with the reluctance of a funeral home to handle the body and the reluctance of a nursery school, under pressure from frightened parents, to continue to enroll the Kushnicks' healthy child, Sara. Both the mortuary and the nursery school relented after the Kushnick's rabbi intervened in their behalf. But Mr. Kushnick did send Sara to another school, and he speaks bitterly about the incident. "What would they have me do," he says, "take my family to a leper colony? "

The 52-year-old father says, however, that he isn't bitter toward the unidentified blood donor, still in good health, who health officials say was the likely AIDS carrier in Sam's case.

"How can you fault someone who thinks he's giving the 'gift of life,' " Mr. Kushnick says.
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