Norman Fowler sets off for San Francisco this week to see how America copes with Aids. BRIAN DEER visits the city where once they said the party never stops
BY the long French window in the Village Deli Cafe, the thin, balding man in his early 20s is straining to take off his sweater. It is a slow and tortuous business, but then that is how Aids very often takes its course.
In the cafe, in San Francisco's Castro Street, there is little talk of Aids. Here, as in any Castro restaurant, sufferers are a common sight and good taste encourages euphemism. Most people now speak of the "health problem", while many closest to the crisis prefer to say nothing about it at all, choosing for the present to concentrate on their lives.
As the man in the sweater settles again, another weary diner, with a brown leather jacket, a walking stick and a plastic tube to his nose, picks his way feebly around the tables. He is clearly very sick and, like the man by the window, his gaunt features and sunken eyes are now the unforgettable face of what was once America's most beautiful town.
This week, in a three-city trip across America, Norman Fowler, the social services secretary, will have an opportunity to see this face, and glimpse what the future holds at home. Graphs showing the rise in Aids cases in Britain almost exactly match the earlier pattern of increase in America, and doctors agree that soon our streets will also have their walking wounded.
"London can expect to go through all of San Francisco's experiences. Fowler has chosen the right place to go," says Dr Charles Farthing, an Aids specialist at St Stephen's hospital in London. "Of all the cities with an Aids epidemic, San Francisco is the only one which has handled it well."
The statistics are staggering. From 1981, when there were just 84 cases of Aids diagnosed in the United States, the number has soared to 29,000, with nearly a quarter of them in California. No accurate figure can be given for the number who have come in contact with the virus, and hence are potentially at risk, but all agencies put this in millions.
With much of urban America, San Francisco has already witnessed Britain's recent debates. Should Aids patients be forcibly detained in hospitals? Is Aids a "gay plague" of no concern to anyone else? Should those affected by the virus be quarantined or banned from certain jobs? Can a police officer catch the virus by giving the kiss of life? Would a campaign on moral values be effective in checking disease?
On every count, San Francisco has found that the answer to these questions is no. As knowledge of the disease and of the people who are at risk has grown, much of the hysteria which engulfed America in the mid-1980s has evaporated. In its place has developed a practical strategy, hammered out by city authorities and the huge self-help network that has grown up.
"The thing that you can learn by coming to San Francisco is that this problem can only be tackled by giving people the information that will let them make their own decisions," says Corrine Whitely of the Pacific Center Aids project. "It is important not to pass judgements on people, but to help them protect themselves and the people they love."
Fowler has already accepted much of this thinking, making the government's media campaign lean towards "safety first" messages, rather than overly moral arguments. His American trip is likely to reinforce his view and could lead to yet more explicit information, found to be the most effective way of changing people's behaviour.
Surveys in San Francisco show that 80% of gay men, still the biggest vulnerable group, have changed their habits so they are no longer at risk of either contracting the virus or passing it on. Although this means that a worrying 20% are behaving dangerously, health workers are encouraged that the incidence of sexually-transmitted diseases has also shown a massive drop. "We have taken the vast majority out of the pool of those at risk," says Holly Smith, of the San Francisco Aids Foundation.
Fowler will also see the city's practical efforts to deal with the crisis. Education programmes have been launched for public service workers such as police and fire officers, home care and hospices for the sick or dying have been set up, and voluntary help mobilised on an unprecedented scale.
But when Fowler begins the steep descent into San Francisco airport this week, he will also begin a journey more impressive in its human terms than any services can suggest. They once said of this idyllic town that the party never stopped - and to witness it transformed by disease, fear and sadness is bound to leave the social services secretary better equipped for his task in Britain.
"Okay it was a party, but the party is over now for both the straight and the gay communities," says Bob Ross, publisher of the Bay Area Reporter which prints columns of death notices for Aids victims. "Every one of us here now has a friend or an acquaintance who has Aids or who has died of it. I think that has made us a more caring community than perhaps once we might have been."