As sponsor of the HIV Prevention Act of 1997, Rep. Tom Coburn (R-OK) has the current distinction of being identified by most of the AIDS community as public enemy number one. All the signs are there, say activists. He is a Christian Coalition -- backed Republican. He sponsored a successful amendment to the Ryan White Reauthorization Act known as the "Baby AIDS Bill" of 1996, which, if voluntary HIV testing of pregnant women does not cause at least a 50 percent drop in HIV infection among newborns by the year 2000, will mandate infant-testing programs.
And now there's the HIV Prevention Act, known inside the beltway as HR 1062. Coburn's intent is to radically change the way public-health disease prevention and containment policies are deployed against AIDS. His bill would exchange the current national strategy based on voluntary, anonymous testing and community-directed education to one that applies more traditional public-health disease-control measures such as routine, and in some cases, mandatory testing and confidential name-reporting of those infected to state governments. The bill is vigorously opposed by virtually every AIDS group, the National Governor's Association and the American Public Health Association.
But Tom Coburn as a person is little-known in the AIDS community. While he is certainly a "traditionalist" in the way he views public health, and his of Christian Coalition viewpoint is clear in that he opposes condom distribution and needle-exchange programs, his views defy strict "conservative" pigeonholing -- especially on health-insurance reform. I have had two lengthy conversations with Coburn, one last November in the Cannon House Office Building and one this past April, when we went to lunch at the Capitol Hill Club across the street.
He is unfailingly polite, a patrician, 49-year-old down-home Midwesterner who graduated from the University of Oklahoma Medical School in 1983 and has since 1986 been a family practitioner specializing in obstetrics. A sophomore congressman, he has said he will run, if he runs, only one more time before returning to his practice. When I talked with him in his office, he had just come home from Muskogee, Oklahoma, where he goes every weekend to attend to patients. Every other Monday he practices at a free clinic in Muskogee. "I built my practice in Medicaid patients," he told me. "Over the break I delivered fifteen babies."
Now he is taking on AIDS, very earnestly. With his mild Oklahoma drawl -- he says "wadn't" and "idn't" and "insurance" -- he leans into his points as he makes them. The Coburn bill has four provisions, and at our lunch I asked him to describe in his own words what each measure would do.
"First," Coburn says, "the bill establishes that cases of HIV infection be reported to the CDC, as we report cases by name of dozens of other infections including hepatitis A, B, and C, measles, rabies, rubella, syphilis, TB, Yellow Fever -- there are 52 in all. Confidential reporting tells us exactly what we need to know about where the epidemic is, and is the ultimate thing needed if you're going to follow-up and stop an epidemic from spreading."
He uses hepatitis A as an example of traditional public-health response to disease control. "The doctor who finds cases of hepatitis A must report it, and that is mandatory. Immediately the health department goes and finds everyone who ate in that restaurant or had exposure, they give them immune globulin, and they tell them, 'Here's the things you should not do over the next six months.'"
He stops to make it clear that name reporting is designed toward prevention, not treatment. "Having said that, reporting has a treatment component. It helps us get treatment to people who need it. It also identifies how big our problem is. Do we have enough money set aside to treat people for AIDS? No, we don't! We have people who can't get triple-drug treatment right now." (Coburn voted last year to increase funds for the AIDS Drug Assistance Program [ADAP], which provides medicine to low-income people with HIV.)
Provision number two establishes state-based partner-notification programs. "Do you have a right to know if you've been exposed to HIV, and is that right less than your right to know you've been exposed to multidrug-resistant TB or hantavirus? Are they different? No. They're all infectious diseases that can take your life," he explains.
Measure number three establishes the doctor's right to routinely test for HIV, without the patient's explicit, informed consent. It contains specific language about the need to protect health professionals from infection, and allows doctors to deny treatment to patients who refuse the test. Still, Coburn says, "Everyone's taking this completely in reverse of what it is. People are saying it's for the doctor's protection. Well, the reason physicians ought to be able to test patients for HIV is that we doctors routinely give all sorts of drugs that are immunosuppressants. Here's an example. A lady I just treated for severe hypothyroidism had refused radioactive iodine. So I told her that before I gave her the alternative medicine, PTU, I wanted to know her HIV status. She said 'What?!' I explained that PTU can suppress her immune system, and if she had the virus, PTU could make her dangerously sick. There are multiple medicines that we doctors use every day that are immunosuppressive." He cited several, including some allergy medicine and vaccines.
The fourth measure gives victims of rape the right to know the HIV status of their accused rapist. "Why should a woman get raped twice, once by the assailant and the second time when she loses her right in the court system to know if she has been infected with a lethal disease? The bill does not give the right to test simply upon an accusation. It is upon indictment, when a grand jury has decided there is enough evidence to bring charges. At that point, why should they not be tested? When I do a rape kit in the ER on a woman, I collect semen and vaginal fluid so they can know the DNA and thus the identity of whoever it was that penetrated her. They can do this test 48 hours after an indictment. Tell me the reason this should not apply, at this same point, to HIV. And with the protease inhibitors, it's extremely important that we know this early because we may be able to avert seroconversion. Why is this not worth a confidential test of a criminal suspect?"
The last two provisions of Coburn's bill are not legally binding. They're called "Sense of the Congress," and one of them pushes states to "criminalize irresponsible behaviors by those who are infected," while the other urges strict confidentiality in all HIV matters. "Confidentiality laws are at this point state laws," says Coburn. "They're good laws but not good enough because in some states we've classified HIV as a disease different from others, and if confidentiality ought to be protected for someone on HIV, it should be for any life-threatening disease."
Given the bill, the question is: Will it help or hurt in the fight against AIDS? I brought up the fears of many infected with HIV -- IV drug-users, gay men in states with sodomy laws and undocumented immigrants -- that confidentiality violations and government lists on which their names would appear could have terrifying repercussions.
Coburn believes that so far, no significant breaches of confidentiality exist. "There is one case I know of where a guy who was HIV positive, who was gay, did distribute to two newspapers a list of people HIV positive from his health department in Florida. He did it to prove you could break confidentiality. Sure you can break it, but why would you want to, other than for political reasons?" If that was the Florida man's point, this answer does not address that such violations can happen for any number of motives, from vindictiveness to blackmail to carelessness.
I asked Coburn at lunch why he had introduced his bill. He replied earnestly: "One of the last people I treated, I diagnosed with HIV. There was no reason for him to have gotten it. It wasn't a needle, he's not gay. He was married. His only risk factor was promiscuity. No one should get HIV today." Coburn added, "I am absolutely convinced that people are getting HIV today who wouldn't have gotten it if we had what I consider a traditional, coherent public-health policy on HIV. And at the same time," he noted, "we should have prevented any discrimination."
It should also be noted that Coburn almost certainly made a basic medical mistake here. When I asked how his bill would have protected this man, he said, "This man I treated is late-presenting. He came to see me with full-blown AIDS; he has a few Kaposi's sarcomas." AIDS-related KS in the U.S. is almost exclusively found among gay men. But that was beside Coburn's point: "If he'd been on medications this past year, he might never have progressed to that point... If you'd had an exposure and were made aware of it, you might seek treatment early. And if you'd recently been exposed to HIV, we might be able to prevent seroconversion. But to do this, you have to know... your HIV status."
Coburn himself readily admits he struggles to stay medically informed about the latest on AIDS treatment. "Most of my HIV patients I try to get to an infectious-disease specialist. I still treat some gay men in Oklahoma because I can't get them to the infectious-disease and AIDS experts, because they have too many patients already. I went down to Dallas this past summer and took an update course on AIDS treatment."
Recently, Reps. Nancy Pelosi (D-CA) and Connie Morella (R-MD) introduced alternative legislation that preserves the current public-health approach to AIDS. Coburn says that it is "clearly just a counter to our bill."
"I sat down with Nancy Pelosi in March and said, 'Is there any way we can work together on this?' But Nancy was just not interested. Their approach is based on civil liberties, not on public health." It was during this meeting, Coburn says, that Pelosi and her AIDS adviser, Dr. Steve Morin, opposed Coburn's rape testing provision. Coburn says they told him that rapists should only be tested on conviction, not indictment. Morin's solution, according to Coburn, is to put women on triple-combination therapy until that time.
Coburn recounted, "When I asked Nancy, 'Do you mean to tell me you're going to put a woman at severe physical risk with these medications, which are extremely expensive, because you don't want to test an indicted rapist?' she didn't answer. Steve Morin jumped in and said, 'Yeah. That is our position.' Well, let's see if Nancy Pelosi is raped by an IV drug-user who is apprehended and indicted, and see if she'd possibly ruin her kidneys, liver and heart taking a very costly medication that is... severely toxic and that she may not need for the six months to a year and a half it takes to get a conviction -- when all they have to do is test this guy?"
Did he ask her this? "No, but it's a good question for her," Coburn said. "A good lawyer can keep a guilty suspect away from a conviction for a long, long time, during which Nancy Pelosi may unnecessarily be taking poison."
Coburn doesn't believe Pelosi's office has taken a sincere look at "what really needs to be done, outside of a jaundiced view that says because there was past prejudice against people who were gay, we cannot trust anyone to do the right thing in the future." He shrugged. "They are closely aligned with the AIDS activist groups and believe what they are told."
I asked Coburn if he could articulate the point of view of the HIV Prevention Act's opponents. "Well, I think so," he said. "From what I've heard, I'm anti-gay and this bill is an ulterior way of getting back at the gay community." We had discussed this idea before. In his office, I had said to him: "You know that people -- gay people -- think you hate them and are afraid of you." He responded almost wistfully. "I know that, and I feel so, so sorry about that."
This time he elaborated. "Homosexuals are no less God's children. That choice of lifestyle, or you'd say that situation" -- he directed that at me, a gay man, because he considers homosexuality a choice -- "is no worse than being unfaithful to my wife or having a standard that is less than what God's standard would be. So do I see gay people as bogeymen and them a group of horrible people? No!" He was quite adamant. "I actually enjoy the time I spend with people who are gay."
When I asked if he could list other reasons for opposition to his bill, he listed current AIDS groups' "loss of control over HIV-related money." "That's going to start being competed with by women and minorities, because AIDS grew by 45 percent last year in the heterosexual population, and my bill will show that's where it's going... Most AIDS money today is controlled by gay interests, and those groups are going to get a smaller share."
I pushed him to tell me more reasons. He thought about it. "I'm not sure I could articulate a further opposition."
OK, I said, let me try these two prongs of attack on you. The first is that these measures just won't be effective at identifying the infected. The second is that even if they are, identifying infections will do no good in the absence of programs -- condoms, needle exchange, housing and behavioral change prevention programs, and most significantly, guaranteed insurance and health care. Could these measures in fact hurt by leading to confidentiality violations, domestic violence and driving people underground? Your opponents, I told him, see you as determined to identify the infected but unwilling to deal with them effectively afterward. In their view, this is an echo of the critique of pro-life conservatives who oppose abortion but also oppose child welfare and neonatal care programs: "Life begins at conception and ends at birth."
"In response to the first argument about effectiveness," Coburn said, "I'd say: Look at how we handled syphilis. After World War II, we had an outbreak, and hospitals mandated that everyone admitted have a VDRL [syphilis] test, as well as all newborns. We instituted reporting and partner notification. It was so effective in controlling the disease that many states have dropped the test because they never get a positive. There are places where we still use it; in Oklahoma it's state law that all newborns be tested for syphilis. And it is ACOG guidelines -- from the American College of Obstetricians and Gynecologists -- that all pregnant women be tested for syphilis. And they're recommending this now for HIV, whereas they used to say you only test women at high risk. HIV is minimal, almost nonexistent, compared to the STD epidemic we have. We have studies that say that 30 percent of women under 25 are probably carrying the human papillomavirus, which causes 94 percent of all cervical cancer in this country. [Other studies say] approximately 25 percent of the people in this country will be positive for genital herpes by the time they're 25. The reason we're losing on syphilis and that it's at a 40-year high is because our public-health policies have been ignored.
"As for the second one, the opposition to HIV testing unless we can treat all HIV, let me use breast cancer as a corollary. That's saying: Let's not do any breast-cancer screening on any women who don't have means of getting treatment. Let's not do mammograms unless they're assured that if they have a lesion, they'll have a surgical consult and all chemotherapy available to medical practitioners. If I stood up on the House floor and said that, people would say I was nuts. We cannot fund every treatment and care aspect of every disease."
I repeated for Coburn something Dr. Thomas Coates of the University of California San Francisco AIDS Prevention Program told me: "Traditional methods like those Coburn advocates are effective, and we need to move toward using them more for HIV. They make increasing sense with the advent of triple-combination therapy. But AIDS has taught us that they are, by themselves, insufficient... that you can't do good public health for STDs without... behavioral change, a mass media campaign, dealing with political and cultural factors, condom distribution, needle exchange, illegal-drug rehabilitation on demand, access to health care -- including prenatal health care -- and treatment, and legislation to protect civil rights."
Coburn is quite clear on his feelings about several of these topics. "I'm opposed to both condom distribution and needle exchange. For needles, we have proved in all addictive behaviors that enabling people doesn't work." You mean, I said, it doesn't work to decrease the behaviors, but we're not talking about that. We're talking about slowing the spread of AIDS. Which it does.
He replied forcefully, "I can tell you that in Europe, needle exchange has not slowed AIDS." I cited a study reported on the front page of The New York Times in November 1996, showing reduction in transmission. "Well," Coburn said, "I didn't see it."
Likewise, he maintains that public-health experts "don't know the true science on condoms." His argument is quite similar to Gabriel Rotello's in his book Sexual Ecology on the so-called lies of "the condom code" (see Read This, June 1997): "I don't believe condoms help prevent sexually transmitted diseases," he said, "because I believe condoms enable people to be more pervasive in their exposure [to HIV], thereby giving them more opportunities to get diseases. All you have to do is look at the risk-reduction studies. The best the CDC has to offer you is a 20 percent relative risk of contracting HIV with a condom. The condom solution is a lie."
When I began to reply that the obvious response to that it's not realistic to expect all young people to be abstinent, he jumped in immediately. "Then we shouldn't have a government policy that says 'Don't smoke cigarettes, they can kill you' because some of them will smoke anyway. And we shouldn't say 'Don't drink and drive' because some of them will drink and drive anyway. We're doing it everywhere else. Why shouldn't we do it [for sex]?"
When I noted that Gabriel Rotello's criticism of the "condom code" closely resembles Coburn's, he said, "Well, he's right. Because we want to say it's OK to be promiscuous, we're willing to rationalize the effectiveness of condoms.
"Forget sex [for a minute]. Using illegal drugs can give you diseases, ruin your life, cost us billions in treatment and punishment and so on. What is our government's policy on drugs? It is opposed. We have spent billions to teach kids not to use drugs, period. So what is the reason for making this behavioral change with sex? The reason is we have more and more children being raised without fathers. We have an STD epidemic leading to an epidemic of cancer of the cervix, which is in turn harming newborns and leading to higher health care costs. And then we get to HIV and a deadly disease. So why wouldn't we want to have a government policy that says, first, that it is stupid to do this behavior; second, it's costly for the individual; and third, it's costly for us as a nation. And forget the moral aspects. I don't forget the moral. I think it's morally wrong to have sex outside of marriage. But I wouldn't legislate that. I only want to use that as a model in my own life and hopefully convince others that that's a good thing -- by pointing out what happens to people who violate that principle."
Coburn's most surprising position, however, is on insurance coverage: He's for making it impossible to lose coverage.
"There's no question in my mind that an insurance company should not be able to drop anyone who's HIV positive," he says. But he opposes a single-payer system such as the one Clinton proposed during his first term. Coburn's solution is a conservative/liberal hybrid of a strong market-driven private insurance industry overseen by equally strong federal regulation.
I asked Coburn about the PWAs who don't already have insurance. His response was, "They aren't different from anyone else who doesn't have insurance." His solution for the infected? "Let's find out how big a problem disease -- all disease -- is in this country, and let's spend the money... The question is, can government be the answer to that problem? No.
"So the solution is a better allocation of funds. Do we spend too little money on health care in this country or too much? Too much -- $180 billion goes to profit for the health-insurance industry. Now you tell me: If we took half that profit, which is based on greed rather than on competition, and applied it, we could cover everyone in this country now."
Coburn wants to make insurance true to its name. "You don't drop people because they get sick. You don't deny insurance for pre-existing illnesses. If none of the insurance companies could deny insurance, guess what? You wouldn't have any problem. Let's get rules where private companies can't discriminate against someone who's sick."
So he would cover everyone who is HIV positive? "Absolutely. I'd make a law that says, 'If you have HIV and you have insurance, you cannot lose your insurance. Period.' I would make that illegal."
So where's the bill? "I've already written it once," he said. "It was in the Baby AIDS Bill, which passed in the House, but they dropped this provision in the House/Senate reconciliation. He showed the bill's language to me: "[I]f health insurance is in effect for an individual, the insurer... may not... discontinue the insurance... solely on the basis that the individual is infected with HIV disease or has been tested for the disease."
"I will launch such a bill if I can get the AIDS groups to launch it with me," he told me. Really? "Absolutely. The minute that happens."
AIDS groups will take that as a challenge, I told him. "They're welcome to." I asked him if this was his way of saying, "Step up to the plate." "Sure," he said.
At the end of the lunch, Coburn grew thoughtful for a moment. "I think there are very smart and courageous people in the AIDS community who, if they really care about others at risk for HIV, will embrace the intent of what we're trying to do. Studies of young gay men in San Francisco show they're not asking each other if they are positive and are not using condoms. We need to know who they are so we can get treatment to them, prolong their lives and maybe cure 'em! If you really care, then you're going to want partner notification, and the group that's going to benefit first is the gay community. That's the answer to it."