Five Quarts: A Personal and Natural History of Blood (16 page)

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. “Minus 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.

E
IGHT

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.

Steve and I woke early to make the drive to San Jose for the 8:45
A.M.
court date. Mile after mile down Highway 101, traffic to our right was a clogged artery as we zipped by in the diamond lane. We arrived with a couple of minutes to spare, only to find the doors of the third-floor courtroom locked, which caused us some distress but seemed not to worry any of the people seated in the hallway. We sat down on the banquette that stretched the length of the windows. After all the trial delays, it now struck me as silly to have thought the sentencing would start on time.

I tried to figure out who all these folks were—the solitary older gentleman dressed in khakis and a T-shirt; the two younger men in navy-blue suits down to the right, lawyers presumably; the man and woman across from us, knotted in conversation. The brittle, waiting-room atmosphere changed in a snap when two more besuited lawyers strode from a courtroom down the hall—both wearing the grin of a happy verdict—and paused to talk to the couple opposite us.

Steve leaned in close. “Do you think that’s her?” he whispered. Beside the doughy man in his midthirties sat an unremarkable silver-haired woman, fifty-something, in a black pantsuit.

“No, I don’t think so.” Over the yawn of months, I’d constructed a mental image of the phlebotomist, or at least a rough outline. In my head she was tall and fleshy and robust. Her sheer physicality accounted, in part, for her ability to deceive and frighten so many people, to inflict such damage. By contrast, the hunched woman seated a few yards away looked tiny and frail. Her shoulder blades jutted from her suit jacket, as if she’d forgotten to remove the clothes hanger when she’d dressed.

“It
is
her,” Steve said, his voice soft but insistent. “She’s with her attorney. Matthews, right? One of those lawyers who just walked up said his name. That’s got to be her.”

“I . . . I think you’re right.”

Steve’s face said pure relief and I knew why: He did not recognize her. For three years, he’d been worrying about the two phlebotomists who’d regularly drawn his blood at the San Francisco lab. Though he couldn’t remember their names, he could picture their faces. This lady was neither of them. Which meant that his blood had, in all likelihood, never caused anyone harm. His
phew
was a lovely sound.

Just then, a deputy emerged from the courtroom and propped open the door. Joining the queue, we followed Elaine Giorgi, her attorney, and a handful of others into the small courtroom. I sidled into the row behind Giorgi’s. As I reached down to lower the seat, I studied her appearance. The first thing I noticed close up: The silvery hair was a wig. She tugged at it and the whole helmet shifted. Either it had stretched or she had shrunken. With her wire-rimmed glasses, lined face, and that hair, she resembled one of the Golden Girls, Estelle Getty’s character.

We’d hardly settled into our seats when the deputy approached and told a few of us that the first portion of the hearing would be closed to the public. As quickly as we’d entered, we were headed back out into the hallway. The deputy was very pleasant and said he’d notify us when we could return. The courtroom door shut. I was surprised by how few people had been inside—twelve at most, including the officers of the court. I’d expected many more, given the media attention that had swirled around this case three years earlier. Where were all the reporters? The TV cameras? In fact, we now waited with just one other person, the older gentleman I’d spotted before. “You must be here for the Elaine Giorgi case,” I said.

“Yes,” he answered, “I’m one of her victims.”

Jerry Orcoff was a big man, about six feet tall, with a bristly white beard and glasses. He looked like the kind of guy who’d give you a good deal at a flea market. As strangers in the same boat, we naturally began to share our stories. Four years ago, Jerry said, he was diagnosed with hepatitis C. At the time, he’d had no idea how he could have contracted this viral infection that’s most common among IV drug users—which he’d certainly never been. Then came the letter from SmithKline Beecham. Jerry realized that the dates matched up—he’d first fallen sick with the characteristic flu-like symptoms shortly after he’d had his blood drawn, one time only, for some routine medical tests. He’d gone to the Palo Alto branch of the lab. He was certain Elaine Giorgi had been his phlebotomist.

Jerry was a retired mechanical engineer, seventy years old, married, and the father of two grown children. Sure, he’d expected to slow down a bit as he grew older, but he never—Jerry couldn’t finish the sentence. He just gave me a look like his dog had died, then shook his head.

Viral hepatitis, as I knew, has six different strains, all represented with letters. A, B, and C are the most prevalent. Hepatitis A is spread through water or food contaminated with fecal matter (every school year seems to come with a news story about kids who’ve been exposed through improperly washed fruit; frozen strawberries are a common culprit). Hepatitis B, like HIV, is most often transmitted through unprotected sex. By contrast, the hepatitis C virus—HCV for short—is exclusively blood-borne and spread primarily through shared dirty needles; less frequently through accidental needle sticks in health care settings and from mother to newborn during childbirth; and, in a small number of well-publicized cases, through shared or unsterilized tattooing equipment. Whatever its initial cause or strain, viral hepatitis can destroy the liver’s ability to perform life-preserving functions, including filtering toxins from the bloodstream and converting blood sugar into usable energy. The most visible sign of advanced disease is jaundice. This yellowing of the skin and eyes indicates that the liver is failing to clear the blood of what are called bile pigments, the yellow-colored by-products of dead red cells. Vaccines now exist to prevent hepatitis A and B, but not C.

HCV, the most common chronic viral infection in the United States, has been labeled “the silent epidemic.” It’s difficult to treat, has no definite cure, and in most cases lingers for years without expressing symptoms. In fact, the virus’s progression can be so slow that an infected person is more likely to die of other causes. But in 15 to 20 percent of cases it quickly brings on cirrhosis, liver cancer, or related illnesses. HCV is the leading cause of liver transplants in the United States.

Jerry, who’s still in a relatively early stage of chronic HCV, is plagued by fatigue, he told us, but not by worse health problems—knock on wood. His disease, which began with a single blood draw, has led to many draws since, he explained, as his progress is monitored through tests of liver enzymes and other markers. “I’m fighting a dragon,” he said, and I first thought he’d chosen an apt metaphor for illness. Then I realized he meant his lawsuit. Like other former patients of Elaine Giorgi, Jerry had filed a civil suit against her former employer, SmithKline Beecham, which is part of one of the largest pharmaceutical companies in the world. A few weeks back they’d offered him a settlement of a few thousand dollars, which he refused. He told us he was hoping his case would go to trial within the year, though he wasn’t betting on it. Dragons are so good at dragging their feet. Regardless, today Jerry Orcoff’s stake in this whole awful mess was not financial but emotional. Today he wanted to see Elaine Giorgi brought to justice. He would have to wait for that, however, as would Steve and I. Right then, the deputy reemerged and explained that, due to some paperwork missing from a probation report, her sentencing had been postponed until August 15.

With a wave, Jerry said, “See you next month,” and strolled off.

The Santa Clara county prosecutor in charge of the case, Dale Sanderson, explained to me that Elaine Giorgi’s bizarre behavior—his words, not mine—went way beyond her boneheaded reuse of needles—my words, not his. For instance, he elaborated, a co-worker had caught her deliberately putting the wrong patient’s name on a vial of blood. Evidently Giorgi hadn’t taken enough blood from someone who’d already left the lab, which isn’t an uncommon mistake. It happens. But rather than calling the patient back in for another draw, Giorgi made up the difference using someone else’s blood. Although I was speaking with Sanderson on the phone, clearly he heard my jaw hit the floor. He was just as aghast. “I mean, can you imagine?” he exclaimed. “Can you imagine going in for your blood results and being told you have a disease that’s not even in your blood?” Or, say, your wife going out partying with friends because she’d been told she wasn’t pregnant when, come to find out, she was?

Giorgi then tried to cover up her mistake by changing the blood work requisition form that the second patient had brought in, so she could take the extra vial. Under the law, these actions, along with other violations she’d committed, were misdemeanors. But Deputy District Attorney Sanderson wanted a felony conviction and its stiffer penalty. Looking back three years to when he’d first received her case, he recalled, “I figured it would be very easy to show that someone who reused a needle puts the entire world at risk.” But that’s not how it turned out. Unable to find a corresponding law on the books, Sanderson thought back to a murder case he’d prosecuted in the late 1980s, “the first pit bull killing case,” in which the dog’s owner was charged with using a violent animal to commit assault. Sanderson believed this case showed a promising parallel to Giorgi’s reuse of potentially deadly needles. In addition, he “dusted off” a statute in the California Health and Safety Code regarding the illegal treatment or disposal of medical waste. Although no health care provider in California, to Sanderson’s knowledge, had ever been prosecuted under this statute, he felt sure he could use it to argue Giorgi’s culpability on multiple felony counts—that in reusing needles she was unlawfully “treating” biohazardous waste.

Sanderson’s strategy withstood the numerous legal hurdles of the preliminary hearings, he explained to me, but, just days before Giorgi’s trial was to begin, the California Supreme Court pulled a significant patch of rug out from under his feet. In its ruling on an unrelated case, the court narrowed the legal definition of the word
likely
(in the charge of “assault with a deadly weapon likely to cause great bodily injury”). This narrowing made it unlikely that Sanderson would get a conviction on Giorgi’s assault charges. In exchange for dropping these, she agreed to plead guilty to the remaining “less egregious” felonies, as Sanderson called them, as well as a single misdemeanor.

The woman who awaited sentencing on the afternoon of August 15 looked different from the one Steve and I had seen in court four weeks earlier. Elaine Giorgi’s silver wig was gone, revealing dyed rusty hair in a ratty cut. If possible, she appeared even thinner and more exhausted, as if she were also suffering the full weight of Jerry Orcoff’s fatigue. While the courtroom of superior court judge Hugh F. Mullin III was electric with last-minute activity as the legal teams prepared to begin, she sat frozen.