David Dinkins’ work on AIDS, TB offers lessons for leaders during Covid-19

By Margaret A. Hamburg
STAT

In the decades before Covid-19, two frightening infectious disease epidemics — HIV/AIDS and tuberculosis — were raging in New York City when David Dinkins became the city’s mayor in 1990. By the time he left office four years later, significant progress had been made on both fronts.

Yet when Dinkins died last month, the reviews of his legacy focused mainly on his historic selection as the city’s first (and still only) Black mayor. But as his health commissioner, I saw a different side of Dinkins that makes him a surprisingly good teacher for our times.

And the story of that moment needs to be told and retold, not only to celebrate an impressive man but to offer a guidepost about the place that science should occupy during crises like the one we’re facing now. Dinkins did something that too many leaders have lacked in their response to Covid-19: he respected science and, perhaps even more importantly, he changed his mind — and the positions he publicly championed — because of it.

It’s hard to remember now just how frightening the HIV/AIDS pandemic was in 1990. New York City had the highest number of cases in the nation, and panic gripped many communities. Uncertainty abounded about the modes of spread. Not long after Dinkins was inaugurated, reports surfaced about the possible transmission of HIV to a patient through a dental procedure. Indeed, the threat of disease lurked in the backdrop of virtually every human encounter, not unlike Covid-19 today.

To curb the spread of HIV through contaminated hypodermic needles, one of the major modes of contagion, public health advocates nationwide had begun to promote needle-exchange programs. But public opinion on these exchanges was split, and understandably so. Many Black citizens and leaders, in particular, feared it would worsen heroin addiction in their communities.

During his campaign to become mayor, Dinkins had denounced needle-exchange programs as a surrender to drug abuse. One of his first public actions was to shut down a small needle-exchange program near the city’s health department.

Then new science emerged.

In the first study of its kind, Yale researchers demonstrated that needle-exchange programs reduced community HIV transmission by as much as one-third. The New York Times ran a Page 1 story about the work. Dinkins called me that day and asked that I talk to the Yale group and find out if such a program would save the lives of people in New York City. With a small team, I analyzed the Yale study, reviewed the literature, and put together a report endorsing needle exchanges.

And then I held my breath.

While compelling, the study had not changed the minds of many of Dinkins’ supporters, whose opposition was driven by strongly held beliefs. Nor had it changed his own clear record of denouncing needle exchanges. What would he do?

At a press conference, he announced he was reversing his position or, in his own words “relaxing his opposition” to needle exchanges. He said he would allow programs undertaken with amfAR, The Foundation for AIDS Research, to be established in New York City. And he also used this policy shift as an opportunity to find higher ground: he would permit the program only if it was linked to comprehensive health care, substance abuse treatment, and other related services.

This was an amazing step, one that even President Bill Clinton (who I later worked for as Assistant Secretary of Planning and Evaluation at the Department of Health and Human Services) did not take and later said was among his biggest policy regrets. In 2015, Vice President Mike Pence, then governor of Indiana, allowed an HIV outbreak to rage out of control in a small community in his state before finally putting aside his own religious convictions and allowing a needle-exchange program.

Dinkins did not stop with AIDS. At the time he became mayor, New York City was also facing a major resurgence of tuberculosis (TB), including an extra deadly drug-resistant strain. After I explained the urgency of the brewing crisis, he reordered priorities, empowering me to develop a comprehensive and integrated TB response plan, including a budget that encompassed the Department of Health; the Health and Hospital Corporation; homeless shelters; and the criminal justice system, including the Rikers Island jail, detention centers, and youth facilities.

Much of the funding went to ensure treatment and targeted interventions wherever people with TB were to be found: in their homes, in clinics, on the streets, in shelters, or in jails and prisons. This included directly observed therapy to ensure that patients took the medications they needed. Funds were also allocated for replacing armory-style homeless shelters in favor of apartment-style settings to reduce transmission in congregate settings; for building a secure TB unit on Rikers Island; and for educating physicians on diagnosing and treating tuberculosis. This comprehensive approach quickly became a model across the nation and internationally.

At the time, breaking down the stovepipes among departments and budget lines was unthinkable. Yet Dinkins understood that such innovation would be required to ensure that resources could be appropriately allocated where they were needed while preventing unnecessary gaps and duplications.

These were the actions of a leader who valued making the right call despite the risks to his political base and future. Moreover, he was willing to provide his full and visible support to pioneering bold new models over outdated ways of serving the public and saving lives.

As we are reminded on a daily basis of the unthinkable challenges that pandemics present public leaders, we should reconsider the legacy of Mayor David Dinkins and his contributions to the health of New Yorkers. But more importantly, I hope that the tens of thousands of city, county, state, and national leaders charged with protecting our public’s health can find in his example the inspiration to look at the evidence and to have the courage to do what works, even when it may not be popular.

Margaret A. Hamburg was New York City’s Health Commissioner from 1991 to 1996 and was later the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services under President Bill Clinton and FDA Commissioner under President Barack Obama.