Donald I. Abrams, M.D.
First, transport yourself back in time to the late 1970s, early 1980s, when solo medical practitioners were the norm in the San Francisco Bay Area. Community physicians, practicing alone in their private practices, were the first to encounter patients with the unusual purple lesion or the rapidly progressive pneumonia. Many of these providers had much in common with their patients--their age, their socioeconomic status, and their sexuality. Even before the establishment of the AIDS clinics at the university facilities, the community physicians were on the front lines as the epidemic erupted. They were truly community providers not only in the contrast to the academicians, but also often as members of the community that was about to become decimated by the ravages of the terrifying new disease. Has such a situation ever before been encountered in the history of medicine?
Recall as well the history of the "Gay Liberation" movement in the United States. In the late seventies, homosexual men and women were just becoming comfortable with emergence from their closets, enjoying an openness and sense of empowerment that accompanied the newfound freedom and acceptance. Nascent organizations of lesbian, gay, and bisexual physicians were being established, initially with the founding of the Bay Area Physicians for Human Rights [BAPHR] in 1977, followed by the national American Association of Physicians for Human Rights [AAPHR (now the Gay and Lesbian Medical Association--GLMA)] in 1981. In fact, it was at a BAPHR meeting of gay physicians from around the country being held in San Francisco in June 1981 that it became evident that these unusual cases of Kaposi's sarcoma and Pneumocystis carinii pneumonia were more than freak isolated occurrences. These organizations served as early foci for information dissemination and educational efforts to alert colleagues and government health officials about the new disease. BAPHR and AAPHR meetings became informal support groups in a way, providing community physicians with a safe haven to share the sense of fear, frustration, and loss that accompanied caring for their earliest AIDS patients, even before the disease was named or the cause was discovered.
Despite an attempt to centralize care of AIDS patients at a center of excellence at San Francisco General Hospital [SFGH], community physicians maintained a desire to care for their patients in their own practices. After all, it was a brand new disease. It is not as if there were a fountain of information on how to treat it that only flowed at SFGH. Although most of the earliest clinical trials evaluating immune modulators and later antiretrovirals were occurring at the General, providers chose to maintain their primary caregiver role. They were undaunted by the novelty of the disease. They were unhampered by the lack of specialty training since there was no such thing as an AIDS fellowship and we were all pioneers, out on the edge of medical history. Plus these men and women were bound to their patients in a unique way. Many of the community doctors had established gay medical practices, focussing their attention on the health needs of gay men. Prior to AIDS, in a young, sexually active population, sexually transmitted disease was the worst of the worries. They expected to establish their general practices and follow their patients through their maturity until old age and death. None of these young practitioners could anticipate the enormous premature loss that they would experience over the ensuing decade, presiding helplessly over the wholesale eradication of their community. Loss of a whole generation of young, intelligent, capable, productive men--like a war without guns. Has such a situation ever before been encountered in the history of medicine?
Read now the stories of some of the generals on the front line in this war. Although not himself a member of the gay community, Jim Groundwater was a favorite dermatologist in private practice for BAPHR physicians to consult. He likely saw the city's first case of Kaposi's sarcoma. Bob Bolan, Jim Campbell, Bill Owen, and Ric Andrews were providers on the front lines, tending to both the medical and psychiatric needs of the community under siege. Stephen Follansbee, completing his infectious disease fellowship just as the initial cases of Pneumocystis carinii pneumonia were diagnosed, became one of the first of the new breed of AIDSologists, his entire early career devoted essentially to the treatment and investigation of the new disease. Another investigator involved in attempting to crack the code from the perspective of the epidemiologist was Paul O'Malley, searching for clues in stored serum specimens and serial follow-up of a cohort of gay men who had been enrolled in a local hepatitis B vaccine trial in the late 1970s. All of these individuals made significant, too often unsung, contributions in the very early days of the epidemic and have for the most part continued on the same course to the present day.
In 1985, Mayor Dianne Feinstein asked Paul Volberding, the director of the AIDS program at San Francisco General Hospital, to establish a line of communication with the community providers caring for patients with AIDS in the Bay Area. The first meeting of the dozen or so providers was held in March at the San Francisco Medical Society. Seeing that many of those in attendance were from the gay community, Paul came to me and suggested that perhaps I should continue the dialogue with these physicians, many of whom he knew to be my friends from BAPHR. Links to my BAPHR colleagues had previously proven very valuable during my oncology fellowship when I established in 1981 a cohort of men with persistent generalized lymphadenopathy to follow prospectively in a natural history cohort. Many of the subjects referred for evaluation were sent by the doctors whose stories follow.
It was my pleasure to preside at the next meeting of the community physicians' group, which was initially formed for a number of reasons. Information exchange was essential in these early days of emerging therapies. As well, we at the SFGH facility saw this meeting as a way to inform the community providers about ongoing research protocols to which they could refer their patients. As the group was a coming together of community physicians and those from the county hospital, County Community Consortium seemed an appropriate moniker. (In time the acronym CCC could never be correctly decoded by those who tried to use the organization's full name, so it was shortened to Community Consortium.)
Within the first year of meeting, it became clear that County Community Consortium providers were interested in taking a more active role in learning how best to care for their patients with the new disease. If memory serves me right, I believe it was Jim Campbell who raised his hand at a meeting and said, "You know, instead of sending all of our patients to SFGH to participate in clinical trials, there are questions we can answer in our own offices." That observation led to the development of a consensus protocol on how to prevent a second episode of Pneumocystis carinii pneumonia [PCP] in patients who had already experienced a first episode. Each provider had their own favorite regimen. Some offered no prophylaxis. Rather than depend on anecdote, we worked to develop a randomized clinical trial that was launched in July 1986 as perhaps the first community-based clinical trial in HIV disease. Soon after its inauguration, the trial was thwarted by the release of the first antiretoviral agent--AZT--because the first patients to receive the product were cautioned not to take any other non-essential medications by mouth. Since patients with a prior episode of PCP now had access to a potentially life-extending antiviral agent, interest in oral prophylaxis against a treatable pneumonia waned.
Undaunted, Consortium physician/investigators next designed a study to investigate PCP prophylaxis using the inhaled pentamidine therapy which had been developed by a UCSF/SFGH pulmonologist. Working together on the inhaled pentamidine protocol, town and gown investigators collaborated in a manner that would become a model for future productivity and success in conducting clinical trials in the sites where patients received their primary care. Ultimately the Consortium's aerosolized pentamidine trial would lead to FDA approval of the modality as the first prophylaxis for an HIV-related opportunistic infection as well as a lead article in the New England Journal of Medicine. It was clear that significant research could be done outside of the hallowed hallways of academic teaching hospitals. This Consortium achievement became a model for community-based clinical trials programs later established by both the American Foundation for AIDS Research and the National Institute of Allergy and Infectious Diseases.
Much of the success of the Community Consortium and even the larger San Francisco Model of HIV care can be traced to the efforts of the physicians whose stories follow. No such collaborative coming together of the community was seen in other areas hard hit by the epidemic. New York and Los Angeles did not pull together the way the community did in the Bay Area. It can be attributed as well to the collaborative congeniality fostered by BAPHR, allowing its member physicians to strike out united against the common enemy--the disease--and not against each other.
I myself owe much of my professional as well as personal growth to my colleagues you are about to meet. Serving as brave, openly gay role models for a young junior faculty academic, initially fearful of coming-out to avoid derailing my career, the examples of these noble, proud and successful professionals inspired my ensuing openness. I write this today with pride as the current president of the Gay and Lesbian Medical Association. Through two decades of battle, these brave warriors on the front line of the fight have unique stories to tell of a struggle to save their community from a plague that often brought as much political as medical despair. Although the battle is neither won nor over, the contributions of the community physicians have done much to enrich the lives of their patients, the medical profession and society-at-large. Has such a situation ever before been encountered in the history of medicine?
Donald I. Abrams, M.D.
Chair, Community Consortium
Assistant Director, Positive Health Program
San Francisco General Hospital
Professor of Clinical Medicine
University of California, San Francisco
Gay and Lesbian Medical Association, 1999-2000
San Francisco, California