The assumption by many decisionmakers that AIDS was similar to other viral agents in being caused by an agent with a short incubation period led to confusion regarding the incidence of AIDS in transfusion recipients or hemophiliacs, given the large number of blood units and blood products transfused annually (FDA, BPAC 1983b). At the time, there was insufficient information to state the mortality rate of AIDS; many believed it was approximately 40 percent or higher (FDA, BPAC 1983b). Decisionmakers did not know the high case fatality rate of AIDS and tended to deny the possibility of an infectious disease agent that could cause a devastating disease that would be fatal to most (if not all) of its victims. This information deficit, combined with incorrect assumptions regarding the natural history of AIDS, led to inaccurate analyses of targeted interventions for donor selection and donor blood testing. Thus, the known costs associated with donor screening interventions seemed to outweigh their benefits, which were unknown but depended on what were still incomplete scientific data.

If decisionmakers had known that AIDS had a long asymptomatic period during which people were infectious, they would have had to admit that the risk of AIDS transmission by transfusion was much higher than "one case per million patients transfused" (estimate of the American Association of Blood Banks, the American Red Cross, and the Council of Community Blood Centers, June 22, 1983; see Chapter 3). In addition, if they had known AIDS was virtually always fatal, decisionmakers might have been more aggressive about donor screening policies.

Lack of Leadership

The January 4, 1983, meeting in Atlanta was an opportunity for someone to take charge, but the meeting ended in disarray. The CDC had expected to leave the meeting with a consensus to draft recommendations to question donors, exclude all homosexuals, and implement surrogate testing (based on work done in their laboratories). The CDC had chosen Jeffrey Koplan, its assistant director for public health practice, to chair the meeting because he was believed to be a neutral figure in the AIDS effort (Curran, Evatt, Foege interviews). Whereas the CDC had hoped to pass the lead role over to FDA (Evatt interview), Dr. Bruce Evatt said he was stunned that the CDC "hit a brick wall" with the FDA. The CDC had been looking for overall agreement, but the crowded and raucous atmosphere made it impossible to achieve consensus (Curran, Evatt interviews).

The American Red Cross representative, Dr. Gerald Sandler, recalled that everyone at the meeting was "very frustrated" that the meeting did not reach a consensus on actions needed. He also noted that not one of Donald Francis' superiors had supported a recommendation to implement hepatitis B core testing. As a result, few in attendance accepted Francis' suggestions, as they assumed



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