Wrongful Death: The AIDS Trial

by Stephen Davis

  Chapter Seven

  “Dr. Fowler, how long have you been Chief of Internal Medicine at Johns Hopkins?”

  “A little over five years now.”

  Benjamin Messick is standing at the lectern, starting to ask questions of his first witness, Dr. Alan Fowler.

  “And after you graduated from Harvard Medical School, what did you specialize in?”

  “Immunology.”

  Dr. Fowler seems very comfortable in the witness stand, Sarah notices. She decides, he must hire himself out as an expert witness a lot. Well, at least Messick is bringing in some big guns to help him out.

  “And have you been published in the field of immunology?”

  Thomas Crawley is out of his chair at the defense table, interrupting. “Your Honor, in the interest of time, the defense stipulates that Dr. Fowler is an expert witness concerning the human immune system.”

  “Thank you, Mr. Crawley. Mr. Messick, you may proceed with your questions.” Judge Watts seems grateful to Crawley for sparing her the time. Messick simply turns his attention back to the witness box.

  “Thank you, Your Honor. ­Dr. Fowler, will you please tell us how the immune system works in a normal human being?”

  “We don't know with 100% certainty....”

  Crawley is up again. “Your Honor, again, in the interest of time, the defense will stipulate to the definition of AIDS that Dr. Fowler will present.” He then turns directly to Messick. “I assume that's where you're going, counselor?” Then he turns back to the Judge. “We’re very familiar with Dr. Fowler; he’s been an expert witness for us in the past, and we know what he's going to say. We would have called him ourselves to present the definition of AIDS, and we are happy to skip all the technicalities and get right to the point.”

  This is definitely not part of Messick’s plan, and he does not want his case thrown off the rails before it even gets going.

  “Your Honor, this is about more than just getting some definition of AIDS on the record. This jury needs to understand at least a little bit of how the immune system works to understand how AIDS is such a deadly disease.”

  Judge Watts motions to both attorneys. “Side bar, please….”

  Sarah leans to her left to see if she can make out what’s being said at the side bar, but she can’t. She hopes that the Judge cuts this short, because the last thing she needs is to sit for hours listening to a high school lecture on the human immune system.

  At the sidebar, Judge Watts also hopes she can cut this short. “Mr. Messick, what’s your point with this witness?”

  “Your Honor, I need to establish how the immune system works, and what the disease called AIDS is, so that the jury can work with the definition rather than just memorize it.”

  Like Sarah, this is the last thing Crawley wants. “Your Honor....”

  But the Judge silences Crawley with a wave of her hand without looking at him or saying a word, and then motions to Messick to continue making his point.

  “I'm going to show that if the defendants had adhered to the very definition of AIDS they propound, my 300,000 clients would have never been given AZT....”

  Crawley tries again. “Your Honor....”

  Once again Judge Watts waves off Crawley’s interruption. “Mr. Messick, I feel a lot like Mr. Crawley here, that you might be wasting our time. But since this is the start of this trial, I'm going to give you some leeway. The minute I think you're losing the jury with unnecessary medical technicalities that can only result in their total confusion, and perhaps a mistrial, I'm pulling in your reins. Understood?”

  “Yes, Your Honor. Thank you.”

  The Judge waves them both back from the sidebar. Crawley hides his disappointment as he sits down again and whispers to Dr. Gallo sitting next to him.

  The Judge announces to the courtroom, “Mr. Messick may continue.”

  Messick repositions himself behind the lectern and scans his notes to refresh his memory.

  “Dr. Fowler, you were about to tell us how the immune system works in a normal human being….”

  “As I started to say, we don't know with 100% certainty. But I brought along some of the teaching aids I created at Johns Hopkins, if that will help.”

  Messick turns to the Judge. “Your Honor, with the court’s permission, we’d like to show the jury a short video presentation….”

  When neither the Judge nor Crawley object, Messick nods toward the back of the courtroom and a large TV is rolled to the front where the Judge and the jury can see it easily. Another big screen is placed in front of the spectators for them to watch. Sarah moves slightly to her right to get a better view.

  With another nod, the lights in the courtroom dim and the TVs come alive. It is Dr. Fowler’s voice on the video.

  “The human body has a wonderful and intricate immune system to help it fight off disease. One of the major components of that immune system is a group of cells called T cells. ­There are several different kinds of T cells, each with its own function. ­For example, ‘T4’ cells are also known as ‘Helper’ T cells.”

  While Fowler narrates, high-tech graphics on the screen portray the Helper T cells in action.

  “They're the watchdogs for the body. They continually search throughout the body, looking for anything foreign they don't recognize, and then notify the body about the invader. For example, if you get a splinter in your finger, the T4 cells will find it and then sound the alarm, warning of a possible danger.”

  The video shows a young boy getting a splinter, and then the camera zooms in toward his finger and seemingly continues right through his skin to show an animated rendition of the T4 cells at work.

  “Or if you come in contact with a strange bacterium or virus, or if you receive a new heart or kidney through a transplant, the T4 cells will activate the body's immune system. In other words, they help the body maintain its health.”

  Messick shoots a glance at the jury to make sure they’re with him so far. They are.

  “What happens next is that ‘Killer’ T cells are released by the immune system....”

  The video is very cleverly going back and forth between live shots of actual Killer T cells and animation of how they operate.

  “...to destroy the invader and also any cells in the body which are presently infected by the outside organism. Then the immune system goes to work to produce antibodies – new ‘special agents’ specifically designed to fight any future invasion by this same intruder. This is the basic theory behind the smallpox vaccine, or any other vaccine.”

  The video zooms back out from inside the young boy’s body, back through his skin, and stops to show him receiving a vaccination in a doctor’s office.

  “In a smallpox vaccination, for example, a very small amount of the virus is introduced in the body intentionally. The Helper T cells alert the immune system; the Killer T cells find and destroy all the smallpox virus and any infected cells; the immune system then creates the antibody against the smallpox virus; and the body is now ready to defend against any future smallpox invasion.”

  Messick interrupts. “I'm going to pause the tape there for a minute, please.”

  As the lights come back up, Messick turns to the witness. “Dr. Fowler, could you boil all that down to one or two sentences for us?”

  Fowler isn’t quite sure how he can make it any easier or simpler to understand, but he’ll give it a shot. “Well, the immune system of a healthy human body protects us from disease using special cells we call T cells to alert the body to an invasion and attack the invader. When we've been successful in our defense, those cells that are fighting the invader are called off, and we make antibodies to fight that specific disease better in the future.”

  “And if this system is working correctly?”

  “We might have some mild symptoms of a disease, but after a short time our body should return to normal and we will usually not have that same disease again, because the invader has been neutralized and we are now protected.”<
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  Messick looks at the jury to make sure he’s not losing them. They still appear to be okay. At least no one is sleeping or looking up at the glass ceiling.

  “But can something happen to interfere with this process?”

  Fowler hesitates a moment to once again find the most basic explanation possible. “Yes, a number of different things. One of the problems with Killer T cells, for example, is that they have to be calmed down and called off at some point or the powerful immune system might damage its own body. If the Killer T cells are operating on their own and out of control, it’s called ‘autoimmune disease.’ So there is another kind of T cell – the T8 ‘suppressor’ cell – whose job it is to stop the immune response and call off the killers. And all these different kind of T cells need to be of sufficient numbers in the body and in the proper ratio to each other.”

  “And what is that ratio?”

  “In a normal, healthy body, there are about a thousand T4 Helper cells per microliter of blood, and a ratio of two to one of T4 Helper cells to T8 Suppressor cells.”

  Messick seems pleased that Dr. Fowler is able to keep this so simple. This is actually going better than I thought it might. Fowler was right when he suggested we use the video. Now let’s see if the jury can stay with it for the next step.

  “Dr. Fowler, what if the numbers are less than normal, or the ratios are off for some reason?”

  “We call that immune deficiency syndrome. That's when...but if you’ll start playing the tape again, Mr. Messick, I think the video will answer your questions. There’s not much more….”

  Messick motions to the back of the courtroom. “Can we have the lights again please?”

  The lights go down, Messick presses “Play” on the remote, and Dr. Fowler’s recorded voice continues on the video.

  “Immune deficiency syndrome is not a new disease. It has been recognized by the medical profession for many years. There are three main causes of immune deficiency syndrome: malnutrition, sleep deprivation, and intentional interference with the immune system through the use of drugs, for instance in organ transplants, to force the body to accept a foreign substance, and in cancer patients undergoing chemotherapy. This intentional interference is known as iatrogenic, meaning caused by the doctor.”

  The TV screen had shown various examples of different kinds of patients demonstrating the different ways the body’s immune system can be compromised. Now another animation starts.

  “What happens to a human body when the immune system can no longer function properly is quite clear. Disease results, either from an outside invader the body can no longer fight off, or from one of the millions of bacteria, viruses, protozoan parasites, or fungi we all carry with us every day of our lives. These are called opportunistic diseases, since they would not occur unless the opportunity arose to attack due to the malfunction of the normal immune response.”

  Messick abruptly stops the tape, explaining, “I need to pause again at this point,” concerned that too much information too fast would send the jury packing. The lights come back up.

  “Dr. Fowler, do I understand correctly that long before AIDS, the medical profession recognized diseases of the human immune system?”

  “Oh, absolutely.”

  “So the immune system, for some reason, would break down, and people would get sick.”

  Fowler finally understood that the video was still too high a level and just how simple and basic Messick wanted him to be.

  “Yes. They would get sick from ordinary diseases that could take hold because there was no functioning immune system to stop them. Again, we call those opportunistic diseases.”

  “Could you name some of these opportunistic diseases?”

  “Well, there’s Pneumocystis carinii pneumonia – commonly known as PCP – cryptosporidium, herpes simplex, candida albicans, cytomegalovirus, toxoplasma gondii, aspergillus, cryptococcus neoformans, nocardia, strongyloides, atypical mycobacterium, papovavirus...”

  Messick remembers the Judge’s admonition. “Okay, Dr. Fowler. Let me stop you there, because most of us...” Messick avoids looking directly at the jury so no one would think he was questioning their intelligence, “…don't understand a lot of those names.”

  “Sorry, yes. Let’s just say that these are all infections by organisms that would normally not cause serious illness in a healthy body. Most of us would never get any of these diseases unless the immune system has been negatively impacted first, and then the disease takes that ‘opportunity’ to make us sick.”

  Messick feels like he’s back on track. “And tell us simply, once again, what would compromise the immune system and allow these diseases to manifest?”

  “Well, no doctor would be surprised to see any of these diseases in a patient who was malnourished, deprived of sleep for extended periods, or already suffering and being treated for another disease or condition with drugs that were known to be immunosuppressive. And there are quite a few drugs that can suppress our immune system – some intentionally as a matter of fact.”

  “Can you give us just one specific example?”

  “The fungus that causes PCP, for instance, is known to inhabit the lungs of almost every human on planet earth, but rarely has the disease been seen in anyone but cancer patients whose immune systems are compromised because of their chemotherapy.”

  That’s enough for now, Messick decides. Let’s get to the point of why we’re here.

  “So, doctor, what is AIDS exactly?”

  “AIDS stands for Acquired Immune Deficiency Syndrome. I figured you were going to ask me that question, so I brought the very first definition of AIDS from the Center for Disease Control in 1982.” Fowler takes out a piece of paper from his coat pocket and begins to read, “‘…a disease, at least moderately predictive of a defect in cell-mediated immunity, occurring with no known cause for diminished resistance to that disease.’” He looks up at Messick again. “Basically, it's what we've been saying, that the person is manifesting a disease they got solely because the immune system had broken down, and we don't know why. We don't know the cause of their immune deficiency. They've acquired it from someplace, but we just don't know where or how.”

  “Dr. Fowler, I’m sure you think that’s very simple to understand, but is there any simpler way you could say this, and make it very specific to AIDS?”

  Fowler sat there for a minute. This was truly a challenge, and he enjoyed challenges. Finally, he gave it a shot. “Well, let me try it this way. It is not uncommon for a cancer patient to get sick from some disease that would not bother a healthy person because we have intentionally destroyed the immune system they need to fight that disease, with drugs that we hope will treat their cancer. In other words, we know why they get an opportunistic disease. On the other hand, an AIDS patient will get really sick from any number of these same diseases that he, too, normally wouldn’t get because his immune system stopped working correctly, just like the cancer patient. But in the case of the AIDS patient, there’s no obvious reason for his immune deficiency. He’s not malnourished, not sleep deprived, and not taking any immunosuppressive drugs ordered for some reason by a doctor. And yet, he has immune deficiency – his immune system isn’t working right any more. And, like the cancer patient, since he has nothing left in his body to fight an opportunistic disease, he will often die.”

  “Thank you, Dr. Fowler.”

  Messick was finished with the witness. His next thought is: What is Crawley going to do? Is he really going to sit on his hands and not cross-examine, as he promised yesterday? Let’s see.

  Messick turns to Crawley and says, “Your witness,” and then sits down at the plaintiffs’ table.

  When Crawley doesn’t stand up or speak, Judge Watts also issues the invitation. “Mr. Crawley, do you wish to cross-examine?”

  Crawley gets up slowly and addresses the Judge directly. “Your Honor, as I said earlier – a lot earlier – we accept the good doctor's definition of AIDS exactly as he said it. And
we could have saved a lot of time….”

  Crawley immediately realizes he had just made a big mistake, and Judge Watts is letting him know by her expression that she’s not at all pleased to be made wrong for her decision to let Messick continue with this witness. Crawley tries to pretend he never started down that road and quickly finishes with, “We have no questions of this witness.”

  The Judge picks up her gavel and raises it in the air, but she pauses at the top of the arc to make sure no one is going to move until she’s recessed the trial and left her bench. She glances around with this look of “Don’t you dare!” and then a few seconds later announces, “We are recessed for lunch. Back at two p.m.” Her gavel finally drops to the podium with a bang. Sarah can hear the Clerk say “All rise” while the massive wave of reporters prepares to overwhelm the courtroom exit.