30 The New York Review
community. Despite the creeping anx-
iety, Slotten writes, the back rooms of
gay bars still offered venues for anon-
ymous sex performed without precau-
tions, as if in defiance of the reports
from the coasts of growing numbers of
deaths. Sex was part of the gay commu-
nity’s emerging self- affirming culture,
Slotten notes, so public health mea-
sures to protect against the disorder
were too often seen as punitive rather
than salubrious:
No one wanted to admit that AIDS
was transmitted through sex....
But as new cases of AIDS were
reported nationwide, public health
officials urged gay men every-
where to start using condoms, even
when having oral sex.... After
struggling so hard to gain accep-
tance, gay men were being told to
give up what they’d been fighting
for, the freedom to love whom
they desired. Hadn’t many straight
people ignored religious dictates
to abstain from sex until after
marriage?...
Despite the surge in cases re-
ported nationwide, there were still
fewer than two thousand at the end
of 1982 and only a handful of them
were in Illinois, a number that
didn’t impress me. Lacking a firm
grounding in the mathematics of
epidemics, I wasn’t as alarmed as I
should have been, especially since
it hadn’t been absolutely proved
that the cause was infectious. The
virus that caused it wasn’t identi-
fied for more than another year....
Like many other young gay men, I
remained in a state of denial about
my risk.Slotten kept a journal throughout
his decades of clinical practice, and in
Plague Years he draws on his notes to
revisit the time when there were no an-
tiviral medications to combat HIV and
restore immune defenses. These only
appeared in the 1990s with the devel-
opment of a succession of agents—first
AZT, then DDI, and then the HIV pro-
tease inhibitors—that were sufficiently
potent to block the virus and allow the
body to recover some degree of immu-
nity. The former were based on older
cancer drugs, the latter entirely novel
agents designed via analysis of the crys-
tal structure of the HIV enzyme.
Slotten does not spare the reader the
physical anguish he witnessed at the
bedside during AIDS’s early years:
Steve... suffered during the last
few months from intractable diar-
rhea, advancing Kaposi’s sarcoma,
CMV retinitis, and neuropathy—
one devastating AIDS- related
problem after another. His lover
Sean confided to me that at home
he exploded in fits of rage, which
upset Sean and their roommate
Heather. On a previous admission
he’d groaned all night, his nurse
Rita had reported, but he told me
that he was “all right.” I knew he
wasn’t. Should he give up or go on?
he asked at every visit. He wanted
to do both but couldn’t decide.
Before becoming ill, he had
worked as an artistic director at
an advertising firm. He had been
a handsome, tall, lanky white man.
Now a beaklike nose jutted out
from a gaunt face. His eyes sank
into their sockets, and when heslept they remained half open like
those of a corpse. Patches of hair
were all that remained of his once
luxuriant mane. When healthy, he
had been self- conscious about his
psoriasis, which spared his face but
erupted in red scaly plaques on his
torso, extrem ities, and pen is. As he
became more immune suppressed,
his psoriasis had all but disap-
peared, for reasons I couldn’t ex-
plain. What replaced the psoriasis
was far worse. He had the papery
tan skin of a mummy. In fact, his
whole lower body was mummified.
Kaposi’s sarcoma had turned his
legs into purple- brown carapaces
and bloated his feet like those of a
dead body floating in a river.Different doctors took different ap-
proaches to dealing with the emotional
toll of caring for the mostly young and
dying. I was trained as a specialist in
blood diseases and cancer, and learned
not to flee from fatal maladies like leu-
kemia, glioblastoma, and metastatic
melanoma. Even so, there were mo-
ments I felt overwhelmed by the misery
of it all. I was fortunate to be able to
leave the bedside for my laboratory,
and find respite working to combat HIV
away from the people it was killing,
testing numerous antiviral agents—
some of which succeeded as effective
therapies while others did not—and
experimental drugs against Kaposi’s
sarcoma.
In the 1990s I began writing, not a
journal, but a book that memorial-
ized some of the patients I had cared
for, seeking to depict their struggle in
the face of familial rejection and so-
cial stigma.^1 Nevertheless, I still felt
what Slotten highlights: a sense of
uncertainty in my role as an effective
physician. As a doctor of family med-
icine, Slotten, much like the physicians
caring for Covid patients today, had
not expected to encounter relentless
death. He is unflinching in examining
his own psychology, the mechanisms he
erected to protect himself, articulating
his sense of deficiency in a bracing con-
fessional tone:In 1992... I had the dubious distinc-
tion of having signed more death
certificates in the city of Chicago—
and by inference the entire state of
Illinois—than any other physician.
How many deaths had I witnessed;
how many more could I withstand
before breaking down?...
Sometimes I wondered what kept
me from throwing myself off the
precipice, either literally or figura-
tively. Perhaps it was my idealistic
sense of duty and refusal to aban-
don my community during its dark-
est hour; or the adrenaline rush I
experienced from being at the fore-
front of a new field of medicine,
which exaggerated my importance
in my own eyes and the eyes of my
patients and colleagues; or the in-
stinctive drive for self- preservation,
which prevented me from having
a nervous breakdown or, worse,
committing suicide; or simply in-
ertia, because maintaining the sta-
tus quo, terrible as it was, seemed
less frightening to me than change,
such as pursuing a different careerin medicine. Questioning motives
sows doubt; doubt leads to indeci-
sion; and indecision to inaction, the
worst possible response to a crisis,
especially for a doctor. So I simply
did not question my motives.Slotten describes how he retreated
into a cold numbness, unable to sum-
mon tears even for those he knew
well, similar to responses now being
reported among frontline Covid care-
givers. He was able to sustain his emo-
tional detachment for months, but then
he would be overcome with a desire for
physical escape. He left Chicago for
trips to faraway countries like Namibia,
and to places filled with aesthetic trea-
sures like Northern Italy:Despite the Jewish guilt—a con-
cept my mother didn’t believe in—I
could continue practicing medicine
only if I interrupted my working
life at strategic intervals when my
spirit flagged. A cliché like “Life is
shor t” b e c a me a m a nt ra of su r v iva l.
Delaying gratification until some
imaginary retirement date seemed
absurd to me, when so many men
my age were dying decades before
their time. I didn’t want to look
back on my life with regret, cursing
myself for putting off the dreams I
could have pursued in my prime.
Although I was HIV- negative, I
behaved like someone who walked
through the valley of the shadow of
death, not fearless but fearful that
the end was near, that the moments
of good health were precious and
shouldn’t be wasted.Only with these periodic escapes from
Chicago could he find respite and be
able to return to face the daily devas-
tation of AIDS.
No one in modern times was pre-
pared for a pandemic like Covid that
has reached across the globe and af-
fected all demographics.^2 Not since
the great influenza pandemic of 1918have doctors and nurses faced a conta-
gious disease that so broadly threatens
themselves, their families, and their
communities, and from which there
is currently no physical or psycholog-
ical escape like Slotten’s, by traveling
to safe places. In my own case, shel-
tering at home and social distancing
block the release I once found with
extended family and friends, the hyp-
notic laps at Harvard’s Blodgett pool,
and the solace at synagogue when I
listened to the Kaddish and whispered
the names of the patients I had cared
for and lost to AIDS. Houses of worship
are now incubators of Covid. Gyms and
pools are closed to limit spread of the
virus.Science ultimately stemmed the AIDS
epidemic. Following the discovery of
the virus in 1983, each of its genes was
characterized, and antiviral drugs were
developed to disrupt the pathogen’s
inner machinery. At first, as Slotten
documents, the gay community was sus-
picious of the scientific establishment,
just as the scientific establishment dis-
missed the tactics and radicalism of the
gay community. But even the most vit-
riolic and confrontational critics, like
Larry Kramer of AC T U P,^3 eventually
wore down and won over government
scientists like Dr. Anthony Fauci; they
and their communities became part-
ners in seeking medications that would
meaningfully benefit the afflicted with
the least side effects. What became
known as HAART—highly active an-
tiretroviral therapy, often called the
“antiviral cocktail” combining nucleo-
side inhibitors like AZT and 3TC with
protease inhibitors like ritonavir and
later integrase inhibitors—now has
been formulated as a few, or even a sin-
gle, pill for many patients, taken once
a day. At the end of The Plague Years,
Slotten celebrates this considerable
change: the death rate among AIDS
patients in the US has fallen dramati-
cally. There are still areas of the nation,
like the South and minority commu-
nities, where rates of HIV infection,
along with other sexually transmitted
diseases like syphilis, continue to rise.
But Slotten, in Chicago, with access to
effective therapies, tells a young man
who recently was infected with HIV,
without hesitation, that there is much
life ahead:It had been almost a decade
since I’d cared for someone with
advanced HIV infection, and I
hadn’t lost a patient to AIDS since- Once a master of the art of
HIV medicine in the era before
HAART, I’d almost forgotten how
to treat opportunistic infections.
Now I would need the internet to
guide me. In 2016 most of my pa-
tients with HIV were vigorous and
healthy, their virus kept in check
by powerful medications.
Slotten writes insightfully on the
pernicious effects of being gay during
the AIDS epidemic, of the shame and
stigma he internalized. But he notes
that AIDS contributed to advancing the
civil rights of gay people in the United
States and many countries abroad. AsRoss A. Slotten at Saint Joseph Hospital,
Chicago, 2016Eric Herzog(^1) The Measure of Our Days: New Be-
ginnings at Life’s End (Viking, 1997).
(^2) Covid has affected primarily the el-
derly, but also many middle- aged and
some young people; disproportionally
African- American and Hispanic pop-
ulations in urban areas on the coasts;
and now those in red states, including
Native American and some Caucasian
residents, particularly those with co-
morbidities like obesity and diabetes.
Essential workers often belong to the
most vulnerable populations.
(^3) Kramer, a vocal critic of federal cor-
ruption and incompetence in confront-
ing Covid, died on May 27, 2020.