by Bill Hayes
I walk around to what appears to be the rear of the building and, at last, locate a doorbell.
A head shoots through a cracked-open door: “You got a delivery?”
“No, an appointment,” I reply.
“Well, this is shipping.” Nevertheless, the young man agrees to take me through the building to the front office, where I’m left to wait in a blah-colored reception area that is conspicuously missing a receptionist. The phone rings over and over. I know she exists because I spoke with her yesterday.
“IDL,” the woman had answered.
I’d hastily dialed the number stamped atop the lab request form Steve takes to the phlebotomist and hadn’t quite formulated the nature of my request, nor to whom I wished to speak. The Chief Blood Tester? Blood Docent? “I’m wondering,” I stammered, “could I come out and just take a look around?”
“A look around what?” she returned pleasantly.
“Well, at the lab. Get a sense of the process involved with testing blood. Maybe, if it’s not too much trouble, take a tour of the facility.”
Long pause. “A tour?” I pictured her scanning the room, thinking, Heavens, what guidebook does he have? “Um, well, we don’t give tours. Are you sure you have the right phone number?”
Oh, yeah, yeah, yeah, I explained, I didn’t need any blood tests myself but was interested in seeing how they’re done. The more I spoke, the odder it must’ve sounded. As if she’d finally caught on, the receptionist said, “Oh, are you with the FDA or something?”
Before I could deny anything, she’d transferred me to IDL’s medical director, the head honcho, Edward Winger. He, thankfully, understood my desire to see what happens to blood in the in-between, after it’s drawn but before the results are sent on. Sure, he could show me how it all works. “How about ten-thirty Friday?”
Before hanging up, I thought, Oh, go ahead, just ask: “My partner just had his blood drawn,” I began, “and I assume you’ll have it by the time we meet. Would it be naÏve of me to think that I could actually see his blood being tested?”
His burst of laughter supplied a thorough answer, but, lest I had any doubts, Dr. Winger added, “Yes, it would be naÏve of you. We don’t track the blood by a person’s name.”
“Oh, for confidentiality purposes, you mean,” I said. “That makes sense.”
“But also,” Dr. Winger added, “almost all of the testing is done late at night.”
Night? So the workers come out to count the blood only after sundown. How vampiric. Well, no wonder parking was so easy.
Dr. Winger enters the reception area. He’s a tall, thin man in his fifties. He has silver-blue eyes behind delicate wire-rimmed frames. Shaking his hand, I find it cool and powdery-dry, as if he has just pulled off a latex glove.
Without further delay, Dr. Winger begins the walk-and-talk, ushering me into the laboratory he founded in 1982. I can see right away that the word laboratory doesn’t quite fit, associated as it is in my head with beakers, bottles, and burners. Immunodiagnostic’s lab is a facility about the size of a basketball court—brightly lit, with white walls and shiny floors. But chilly. Now I understand why Dr. Winger wears a heavy flannel shirt on this Indian summer day. I spot a total of three people in work areas scattered about the floor. In lieu of introducing me to his staff, however, over the next hour Dr. Winger will introduce me to his machines.
The first pair handle what is called viral load testing, which provides a measurement of the amount of HIV in a person’s blood. A decade ago, the best test of this kind was the p24 antigen, which only gave a Yes or No answer to the question, Is the virus actively replicating? It worked by searching the blood for a discarded part of HIV, a method akin to determining if a McDonald’s burger has been eaten by rummaging for the tossed wrapper. By contrast, today’s viral load tests zero in on the Big Mac itself, the genetic material in HIV. They quantify how virulent your virus is as well as whether or not the pills you’re taking are having an effect. The two machines before me aren’t large or imposing, but their power to change a person’s life is enormous. How the tests work, though, is complicated, and I pay a price for my momentary lapse in attention. Dr. Winger is in the midst of describing the most sensitive of the three types of viral load tests, the Q-PCR:
“. . . so we have a single-stranded molecule and another single-stranded molecule here”—Dr. Winger is now also drawing—“and what happens is, we end up having only this region here being copied, and then, well, then we get a double-stranded molecule.”
He makes a new addition to his notepad. “You see this?”
Yes, I see what looks like a drawing of venetian blinds—strips of flattened DNA, I gather, nodding. But Dr. Winger has already moved on. He draws two graphs that look like sales curves.
“With each cycle, we get a doubling of just this region here and it amplifies geometrically . . .”
Dr. Winger’s verbal momentum is gaining speed, yet I am utterly lost and feel only a little regret at pulling out his power cord. I ask for the layman’s version and he obliges, although, at first, it is still more of the Dr.-Layman-Ph.D. variety. But finally, he breaks it down this way: They take a sample of blood—less than half a teaspoon—then remove a single fragment of DNA from an HIV particle and clone, or “amplify,” it. Using a mathematical formula, they then calculate the number of viral particles, or “copies,” originally present in the sample. This number is an accurate fraction of the total amount in the bloodstream. Okay, that makes sense, I think, but Dr. Winger cannot resist a big textbook finish: “There’s a rule of thumb that the number of cycles required is inversely related to the log of the starting copy number.”
What’s not lost on me is the impact these results will have in the doctor-patient sit-down. There, it’s not a number you hope to see but a word. When fewer than fifty copies are found in a patient’s blood, the Q-PCR test finding is labeled “undetectable.” Fifty copies may sound like a lot, but this is actually an infinitesimal amount of HIV. The take-home message is, if your virus is undetectable, your drug cocktail’s working and viral activity is at a virtual standstill. Though its diagnostic meaning is unambiguous, the casual use of the word has caused problems. When doctors announced in 1997, for example, that Magic Johnson’s virus was undetectable, many fans took this to mean that the former Laker no longer had HIV. It didn’t help that his wife, Cookie, declared in an Ebony magazine interview that Magic had been “cured.” His doctors “think it’s the medicine,” she’s quoted as saying. “We claim it in the name of Jesus.” But no miracle had occurred. In fact, after Johnson later neglected to take his meds during a long vacation, his viral load shot back up to detectable levels. My partner Steve has put his own spin on this semantic confusion: Undetectable is a lot like the Invisible Woman from the Fantastic Four—just because you don’t see her doesn’t mean she’s not there.
Dr. Winger explains that, of course, PCR testing has other applications outside of HIV care. It serves an essential role in forensics science, for instance, by isolating the DNA “fingerprint” of blood or tissue evidence found at crime scenes. And the killer is . . . !
At this point in the tour, I’m realizing how loudly he and I have to talk to be heard over the racket made by these two machines. (What must this place sound like in the middle of the night, when all the machinery is in high gear?) We stand before the apparatus that is used to isolate the DNA molecule. Though it’s not much larger than a toaster oven, it sounds like a dryer filled with tennis shoes. The thumping, Dr. Winger explains, is made by a piston that pushes cell particles through an interior tube at a pressurized weight of more than three thousand pounds per square inch. I mouth wow back to him.
We now move on to other noises. Loudest of all are two liquid nitrogen tanks. These are powered by individual generators that are doing a good imitation of cement trucks. The tanks, which resemble a large pair of bongos, are where tissue and cell cultures are preserved. “They’re cold as hell,” Dr. Winger specifies. “Mi
nus 195 degrees Celsius.” As he unlatches one of the lids, fog-like vapor overflows. “Put your hand down in there,” he urges me, flashing a triangle-shaped smile. “But don’t touch the sides!” I’m reluctant—I’ve seen The Empire Strikes Back too many times not to flash on Han Solo being frozen in carbonite—but I summon the wherewithal to dip my index finger in partway. “Very, very cold,” Dr. Winger chirps. “Exceptionally cold.”
Continuing on in the doctor’s wake, I realize that I haven’t seen any blood anywhere in the lab, not a drop of red in the sterile sea of white and black and bland equipment. I’d expected to see rows and racks and stacks of vials. But, as in the body, the blood at IDL is just under the surface. It’s concealed within machines. It’s stored behind refrigerator doors. For certain tests, it’s kept in incubators, body-temperature warm. I know that there are five vials of Steve here, someplace on the premises.
Every specimen that enters this facility is stripped of its identity, Dr. Winger tells me. Each vial is bar-coded, and its every move through the lab is monitored by computer. This makes for the easy and accurate assembling of test results from many machines. The computer does not make mistakes, he states evenly. It strikes me that the whole process is, as much as possible, devoid of human touch and emotion, but also of human error and carelessness. Unbidden comes the memory of that letter Steve received from his previous lab with the news of the phlebotomist who’d reused needles. But I’m comforted by all that surrounds me. His blood’s in good hands here, during this part of its journey, just as he himself is with his regular IDL phlebotomist, Rosemary.
Pausing for a moment in the center of the lab, Dr. Winger quickly points out some of the noteworthy machines around us: “This is an ELISA reader, Western blots here, blood chemistries over there. Immunochemistry stuff. Urinalysis. Blood coagulation panels. Over there is the DNA synthesizing machine, which is synthesizing as we speak.” Across the room, that’s an ultracentrifuge, a device for spinning plasma at superhigh speeds—“It’s forty thousand times gravity in that thing”—a process that separates the component parts of cells.
Amid all this expensive high-tech equipment, I spot something familiar. “That looks almost like a microwave,” I say.
He grins a you-got-it. “There’s nothing better than a microwave for making basic heat-dried stains,” he admits. “It’s the only thing here under a hundred dollars.” This last bit he adds with an air of amusement. They’d just had to send back a quarter-million-dollar piece of equipment that had turned out to be a real lemon. Go figure.
As I follow Dr. Winger toward the last stop on my tour—the T cell tabulator—my mind wanders backward. T cell counts, unlike, say, the newer viral load tests, have been the through-line of Steve’s long life with HIV, albeit a through-line with peaks and plummets. Of the various T cells counted—helpers, killers, and suppressors—the helper T’s are the most important indicator of how your immune system’s doing in fending off the virus. In a healthy person, a normal helper count—often simply called T cells, for short—could be as high as eighteen hundred per cubic millimeter of blood; in a person with advanced HIV disease, it could be eighteen, or zero. Falling below two hundred is the criterion for an AIDS diagnosis. This truck hit Steve in the summer of 1994. Following that, he had to get T cell counts every four weeks as his immune system continued to deteriorate. Watching those numbers descend was a helpless feeling, since Steve had already done every antiviral available and the next wave of meds, the protease inhibitors, was still a year off. It was like he was stranded in the desert and could only watch as his water supply fell.
In the early years of the AIDS epidemic, T cells—as well as all blood cells, for that matter—were counted by hand. In my head I pictured row upon row of white-coated lab techs, all hunched over microscopes, quietly tallying cells with calculators, and all, in a curious casting choice, middle-aged women. The row of ladies who tallied T cells looked more beleaguered than the rest, I imagined. I actually worried about them, faced day after day with the blood of the very ill. I hoped they gave out a private hoot when a robust sample came through. In some parts of the world, these kinds of counts are still done manually. During a recent tour of an AIDS clinic in Rwanda, a friend told me, he watched as a woman laboriously counted blood cells, an eye to a microscope lens, a finger on a simple clicker.
Dr. Winger and I stand before the Flow Cytometer, the state-of-the-art cell tabulator, a machine that, to me, would not look out of place at a Kinko’s. He introduces Mark, the technician who operates it, but then backtracks a bit to remind me of a basic fact of hematology: White cells look a lot alike. While it’s easy to tell the difference in a blood smear between, say, a red and a white cell, the distinctions among the types and subtypes of lymphocytes are subtle. “You can’t tell a helper T from a suppressor T cell under a conventional microscope,” he explains. But there’s a way around this. By introducing into the blood sample what’s called a monoclonal antibody, the specific white cell you’re trying to count will be “tagged.” Next, a dye is added that stains the tagged cells.
“How very Paul-Ehrlichean,” I comment.
“Exactly. It was his idea to couple antibodies to dyes and use them to identify cells.”
“But today this is all done by computer.”
Dr. Winger nods. The dyes used are fluorescent, which makes them recognizable by laser. He next points to a rectangular black contraption, the contents of which aren’t visible. “We put a test tube of blood in a carousel down there, and Mark here tells the computer we want to ‘interrogate’ certain stained cells. So, for example, it allows us to look at T helper cells only.”
“You say look at them, but you’re never looking at the cells directly.”
Well, no, he concedes, but the computer is. “Every single cell passes by a sensor head that inspects it.” At the same time, the flow of cells is shown on a computer screen. Sure enough, Dr. Winger points to a monitor where a meteor shower of gold pixels is shooting across a black field, left to right. These are T cells. I have no reason to believe they’re some of Steve’s, but then again, who knows? Either way, I find myself transfixed, rooting for a high count. I wait until I’m sure several hundred have flown by. Now it’s safe to move on.
EIGHT
Blood Criminal
THE CRIMINAL TRIAL OF THE SMITHKLINE BEECHAM phlebotomist accused of deliberately reusing blood-draw needles was scheduled to commence in mid-August 2001, more than two years after Steve and thousands of other patients had first been notified of this woman’s dangerous actions. How often she’d reused the butterfly needles and with which patients remained unknown or, at least, unreported. Either way, the math didn’t look good. She had been employed by the lab off and on over six years, during which she’d had contact with up to twelve thousand people. (In a sickening coincidence, the last of the eighteen times Steve used a SmithKline lab resulted in the blood work that gave him his AIDS diagnosis.) He and I had never seen a photo or news footage of the “renegade phlebotomist,” as she was called in some early media reports, and we didn’t learn her name until a May 2001 newspaper story provided details of her upcoming jury trial. Elaine Giorgi faced six felony charges, including assault with a deadly weapon—dirty needles. Though she’d worked at SmithKline labs throughout the Bay Area, the charges had been filed in Santa Clara County. The trial, in which she’d be represented by court-appointed attorney Brian Matthews, was to take place at the San Jose Hall of Justice.
I wasn’t surprised to learn that the first session served as an opportunity for her lawyer to request a delay, which was granted. But I never expected that, over the next year, her trial would be postponed ten times due to assorted legal matters. I was anxious to get a good look at Elaine Giorgi and to hear how she justified what she herself had admitted to doing “occasionally.” And then, in July 2002, the prosecutor dropped the most serious assault charge and Giorgi pleaded guilty to separate felony violations of illegally disposing of medical waste. There would
be no jury trial after all, only a sentencing. She faced a slew of fines and a maximum of five years in state prison.
The picture I had in my mind of what a blood criminal looked like ran a continuum, from the sublime to the horrific. During the summer of the bloody glove and the O. J. trial, a trio of Italian bank robbers stole a couple of watts of the media spotlight after helping themselves to five-figure sums from more than ten Turin banks. Up through their capture, their brazen acts won them cheers, especially from people with HIV, for these Bonnie-less Clydes had AIDS and a legal loophole on their side. A 1993 “compassionate release” law in Italy prevented the terminally ill from serving jail time. In those days before effective drug cocktails, the three’s spree demonstrated a fearlessness that, here in San Francisco, raised a few spirits and felt downright therapeutic. Silenzio = Morte!
No smiles surfaced two years later for Nushawn Williams. This nineteen-year-old, arrested in 1997 in New York State, became the face of criminal HIV transmission when he was accused of deliberately infecting thirteen young women, including an eighth-grader, through unprotected sex. Each new revelation added to the horror. He traded drugs for sex. He kept records of his exploits. He may’ve exposed nearly fifty individuals. He said he didn’t believe the social worker who’d told him the previous year that he was HIV positive. Williams later pleaded guilty to four sex-related felonies, including statutory rape and reckless endangerment. He was sentenced to four to twelve years in state prison, where he’s currently doing time. His parole was denied in 2001, and again in 2003.
Now joining this rogues’ gallery was Elaine Giorgi.
