Dedication

This report is dedicated to Spencer Cox

March 10, 1968–December 18, 2012

Walter Kurtz Photography © 2006

Melanie Thompson, MD

New York City, June 11, 2013

I am so honored to be part of this ceremony to celebrate a man I loved dearly, my friend and patient, Spencer Cox.

When I met him in the very early 90s, Spencer was one of ACT UP’s youngest stars, a leading member of the Treatment and Data Group, and later, chair of TAG’s Antiviral Drugs Committee. He was bright and beautiful and charismatic. His wit did not disappoint.

I had been in HIV research for only a few years, fighting at the national level from the clinical side for accelerated access to, and approval of, potentially lifesaving drugs to fight HIV. Conducting trials of monotherapy ddI, ddC, d4T, my research colleagues and I were desperate for something to stem the tide of unrelenting death. AZT was approved after 19 died on the placebo arm, but ddI was approved on the basis of a 10 T-cell improvement, in spite of pancreatitis and neuropathy. And ddC and d4T won approval on similar shaky grounds in spite of even worse neuropathy. It was the common wisdom in those days that the chance at life was worth a few painful or numb feet. And protease inhibitors were in the wings, with rumors of unprecedented potency.

Then in September 1994, this young man, this Spencer Cox, appeared before the FDA (representing TAG) and everything changed. Having fought hard for accelerated drug access, he now chastised the agency, researchers, and pharma about the danger of rapid approvals in the absence of true efficacy data, potentially putting patients at risk for little or no benefit.

“The approval of therapies based on inadequate, ambiguous, uninterpretable, or incomplete data offers severe and often insurmountable difficulties in the future evaluation of new treatments,” he said. “This is the deck with which the current therapeutic house of cards was built.”

And then he ended: “In short you must ask yourselves, ‘Can we do better?’ Damn right you can.”

When the protease inhibitor ritonavir appeared on the scene, it was in a trial designed by Spencer and others. The new trial design led to unambiguous proof of efficacy and ritonavir was licensed in record time, setting a clear and rapid path for others and leading to over 8 million people receiving combination antiretroviral therapies today.

Liquid ritonavir, by the way, in addition to being god-awful in taste, caused a change in taste perception, which was termed “taste perversion.” Spencer defined this taste perversion as “the inexplicable desire to wear plaid.” The mystery of his many plaid shirts is now solved.

These were the miracle times—the Cocktail Days. People were living instead of dying: going back to work, starting new careers, joking about buying long-playing records. The Plague Years appeared to be, themselves, dying. AIDS was over.

Spencer left activism in the late 90s. He had to. But in many ways, the Plague Years were the best of times for him. There was a cause for which to fight. Miracles happened, after a lot of hard work. For Spencer, and for many other (largely white) gay poz activists, there was true community in the committee meetings as well as die-ins at the FDA, St. Patrick’s cathedral, and the NIH. There was love—the beloved community. People cared for one another in the most basic of ways: cooking meals, ferrying to doctor visits, cleaning the sick and then burying them—all done together.

But when AIDS died for Spencer, so did the beloved community. Now no longer a baby activist, now having graduated from the Universities of ACT UP and TAG, the 30-something-year-old began to revisit the life that the 20-something-year-old Spencer had put on pause in order to battle death. He was not well prepared for the realities of a harsh, individualistic world without the focus of a mission and safety net of its caring institutions. Survivors like Spencer were expected just to be grateful to be alive and to get on with it. Like many, Spencer had been in the foxhole and seen multiple losses, just barely escaping with his own life. For some survivors, getting on with it was not so simple, because what “it” was was not entirely clear. Michael Callen said, “AIDS is the day-to-day management of uncertainty.” But in the Cocktail Days, it was the challenge of living instead of dying that was brimming with uncertainty.

Spencer and John Voelcker founded the Medius Institute. As Spencer struggled with depression, his keen insight led him to observe that many Plague Survivors shared a syndrome not unlike that of combat veterans, posttraumatic stress disorder. But for these gay men, PTSD included high-risk-taking behavior, drugs, guilt, and shame as well as depression. Crystal meth was the drug du jour. He wrote scholarly white papers on depression and PTSD for Medius. But in the heady days of viral suppression, there was eagerness on the part of the media and the LGBT community itself—just as there is today, unfortunately—to forget about AIDS.
The Medius Institute did not survive.

In 2009, depression and despair led to crystal meth, abandonment of ART, and the onset of life-threatening illness that landed him in a coma in a New York hospital. When he was well enough for discharge, he was released to heal in his mother Beverly’s loving custody in Atlanta. I was honored to be his doctor, but when he walked through the door I hardly recognized him. We saw a lot of each other, needless to say, over the ensuing months that stretched to years. One by one, we patched up residual illnesses and played whack-a-mole with new ones. But finally, he began to bloom again, like the purple morning glories he raised from seed and posted on Facebook. He became the old Spence, with T cells to spare, and suppressed virus.

Spencer became a social media animal, a regular on Gawker, Twitter, Facebook. He had 1,347 Facebook friends, all drawn to him because of his acerbic wit and his mushy soft center. He regaled us with Puppy Porn, pictures of baby otters, recipes for meals he cooked, date invitations for James Franco, and ongoing ruthless commentary on just about anything. He summed up the presidential election by observing: “They have Ann Coulter. We have Cher. We win.”

When How To Survive a Plague came along, it further enlivened Spencer. He was a star and he lusted for the Red Carpet, mostly to provide ripe material destined for harvest in catty posts. He shared the trailer with me with great pride. And partially due to this energy and the reconnection with friends that came with it, he declared that he was now ready to move back to the City.

Then last December I received a call from a young intern at a New York hospital. Spencer was again at death’s door. I provided a full medical history, as far as it went. “Looks like he just stopped taking his meds. It’s a shame how these guys just don’t get it,” he said. Needless to say, the young intern got a vigorous “schooling” from me.

Unfortunately, we doctors are often the ones who just don’t get it. Our patients have complex lives. For even the best and brightest, antiretroviral therapy is not enough. And that’s why it’s so important that this clinic is being named for Spencer Cox.

Our biggest challenge for HIV care in America in 2013 is not the absence of effective drugs. Our biggest challenge is that our medical system, in general, is not structured to help people with HIV to get in care, stay in care, and take their drugs successfully. We human beings have messy lives. We need navigation to help us get back on a path when we fall off, and care for our emotional and mental health as well as drug therapy for the virus. We need treatment for other illnesses like hepatitis C, cardiovascular disease, and diabetes. And as we grow older, we need all of the above times two.

So it is with pride that I see Spencer’s name appear on the face of this excellent clinic. This is the type of clinic that has the potential to bridge these gaps. I urge you to remember Spencer as you go about your work here. Be angry that he died. Use your power to fix our system. Remember that health is more than the absence of illness, and care is more than drugs. I challenge you to work hand in hand with your patients to become that model for a new beloved community that all patients need.

I hope that every day, when we awake, we ask ourselves, “Can we do better?” And I hope we answer: “Damn right we can.”