715.Garrett, L., “AIDS drugs fading: New prevention approach sought.” Newsday(August 31, 1999): A4; and Wainberg, M. A. and Friedland, G., “Public health implications of antiretroviral therapy and HIV drug resistance.” Journal of the American Medical Association 279(1998): 1977-1983.
716.例如，1994年在纽约市有将近7000人死于艾滋病。到1996年年底，这一数字已经下降到5000人。而1998年的粗略数据显示，詹姆斯的死亡可能只是3500人中的一例。美国大多数主要城市也出现了类似的趋势。全国艾滋病死亡率在1996—1997年间惊人地下降了的47%。
欧洲有一个更为戏剧性的趋势：1994年至1998年，艾滋病患者的死亡率惊人地下降了80%。在欧洲取得更大成功的原因可能是更广泛地获得医疗保健（有4300多万美国人没有保险，而西欧几乎普及了医疗保健），以及1980—1995年间在使用实验性抗艾滋病病毒药物方面更为保守。（后者可以解释欧洲和美国艾滋病患者的多重耐药率相对较低。）
717.1998年11月，作者的访谈记录。
718.这些和其他关于鸡尾酒疗法的评论都是在1998年和1999年的采访中收集到的，除非另有说明。
719.Barr, M., “Now what? Maverick researcher Dr. Steven Miles explains why the next great drug isn't coming and what we can do to redeem the dream of a cure.” POZ (October 1999): 60-63; Cooper, D. A. and Emery, S., “Therapeutic strategies for HIV infection—time to think hard.” New England Journal of Medicine 339 (1998): 1319-1320; and Garrett, L., “AIDS after the ‘cure’ : Amid setbacks search for new hope.” Newsday (June 14, 1998): A7.
720.1998年10月，作者的访谈记录。
721.Finzi, D., Harmankova, M., Pierson, T., et al., “Identification of a reservoir for HIV-1 in patients on highly active antiretroviral therapy.” Science 278 (1997): 1295-1300;Grossman, Z., Feinberg, M. B., and Paul, W. E., “Multiple modes of cellular activation and virus transmission in HIV infection: A role for chronically and latently infected cells in sustaining viral replication.” Proceedings of the National Academy of Sciences 95 (1998): 1-6; Paul, W. E.and Grossman, Z., “Ongoing HIV dissemination during HAART.” Nature Medicine 5 (1999):1099-1104; etc..
722.“Abnormal fat distribution and use of protease inhibitors.” Various letters in Lancet 351 (1998): 1735-1737; Carr, A., Sarnaras, K., Thorisdotter, A., et al.,“Diagnosis, prediction, and natural course of HIV-1 protease-inhibitor-associated lipodistrophy, hyperlipidaemia, and diabetes mellitus: a cohort study.” Lancet 353 (1999): 2093-2099; Carr, A., Sarnaras, K, Chisholm, D. J., et al., “Pathogenesis of HIV-1 protease inhibitor-associated peripheral lipodystrophy, hyperlipidaemia,and insulin resistance.” Lancet 351 (1998): 1881-1883; etc..
723.Carr, A. and Cooper, D. A., “Gap between biology and reality in AIDS.” Lancet 352(1998): siv16-siv17; Gazzard, B. and Moyle, G., “1998 revision to the British HIV Association guidelines for antiretroviral treatment of HIV seropositive individuals.” Lancet 352 (1998): 314-316; Goldstein, R., “Climb every mountain: The art of selling HIV drugs.” POZ (October 1998):64-67; Louis Harris and Associates, Inc., National HIV/AIDS Treatment Survey. Washington, D.C.:Johns Hopkins University and UCSF, June 13, 1998. Offfce of AIDS Research, Adherence to New HIV Therapies: A Research Conference. Washington, D.C., November 21-21, 1997; etc..
更糟糕的是，鸡尾酒疗法失败，就时间而言对个别患者，似乎是一个不可预测的随机事件。但从长远来看，这是一个不可避免的事件。
724.1999年，对预防性药物的需求有所缓解，因为医生发现对鸡尾酒疗法反应良好的患者往往有足够强的免疫系统来控制这些病菌。
725.Condra, J. H., “Resisting resistance: Maximizing the durability of antiretroviral therapy.” Annals ofInternal Medicine 128 (1998): 951-954; Durant, J., Clevenbergh, P., Halfon,P., et al., “Drug-resistance genotyping in HIV-1 therapy: The VIRADAPT randomized controlled trial.” Lancet 353 (1999): 2195-2199; Hirsch, M. S., Conway, B., D'Aguilla, R. T., et al.,“Antiretroviral drug resistance testing in adults with HIV infection.” Journal of the American Medical Association 279 (1998): 1984-1991; etc..
726.鸡尾酒疗法药物随着时间的推移会失去效力，这种看似神秘的趋势的一个解释是简单的人体生理学。每天服用5到10种甚至是轻微毒性药物的人，都会使他的肝脏、肾脏、肠道和肠道受到真正的打击。随着时间的推移，这些重要器官吸收和处理药物的能力下降，因此抗病毒药物永远无法到达目标。病人可能会遵从医生的医嘱，但肝脏或十二指肠则不然。
727.Coombs, R. W., Speck, C. E., Hughes, J. P., et al., “Association between culturable human immunodeficiency virus type 1 (HIV-1) in semen and HIV-1 RNA levels in semen and blood: Evidence for compartmentalization of HIV-1 between semen and blood.” Journal of Infectious Diseases 177 (1998): 320-330; Dyer, J. R., Kazembe, P., Vernazza, P. L., et al., “High levels of human immunodeficiency virus type 1 in blood and semen of seropositive men in sub-Saharan Africa.” Journal of Infectious Diseases 177 (1998): 1742-1746; etc..
728.1999年1月，作者的访谈记录。
729.这种失谐的酶联免疫吸附测定法于1998年发明，1999年在美国少数几个卫生部门投入使用，这是第一次让各机构看到它们的艾滋病疫情。他们所看到的往往掩盖了长期以来关于谁感染了艾滋病病毒的假设，并揭示了艾滋病预防策略的严重缺陷。
730.标准的艾滋病病毒酶联免疫吸附测定法检测血液中是否存在抗病毒抗体。精细的、高度调整的酶联免疫吸附测定法可以在免疫系统对病毒产生完全反应之前，在感染的最初几天甚至可以检测到极少量的抗体。失谐的酶联免疫吸附测定法则恰恰相反，只发现了感染后3到5个月出现的大量抗体。通过同时使用标准和失谐酶联免疫吸附测定法，实验室技术人员可以判断个体可能处于哪一阶段感染。
731.McFarland, W., 1999, op. cit.
732.Altman, L. K., “New York study finds gay men using safer sex.” New York Times(August 28, 1999): A1.
733.Centers for Disease Control and Prevention, “Increases in unsafe sex and rectal gonorrhea among men who have sex with men—San Francisco, California, 1994-1997.”Morbidity and Mortality Weekly Report 48 (1999): 45-48; Centers for Disease Control and Prevention, “New data show decline in AIDS deaths slowing down.” Press release. Atlanta,Georgia, August 30, 1999; Handsfield, H. H, “Resurgence of syphilis and gonorrhea in men who have sex with men, Seattle-King County, Washington.” Morbidity and Mortality Weekly Report 48 (1999): 773-777; and San Francisco Department of Public Health. San Francisco Monthly STD Report. June 1999.
734.New York City Department of Health, “Increased rates of hepatitis A among men who have sex with men.” Memo. New York City: Bureau of Communicable Disease, July 13,1998.
735.Osmond, D., Charlebois, E., Page-Shafer, K., et al.,“Increasing risk behavior has not led to higher HIV incidence rates in the San Francisco Young Men's Health Study: 1993-1998.”Twelfth International Conference on AIDS, Geneva, June 28-July 3, 1998.
736.Ekstrand, M. L., Stall, R. D., Paul, J. P., et al., “Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status.” AIDS 13 (1999): 1525-1533.
737.Elovich, R., “Beyond Condoms.” POZ (June 1999): 86-91; Gendin, S., “They shoot barebackers, don't they?” POZ (February 1999): 48-71; Rotello, G., Sexual Ecology: AIDS and the Destiny of Gay Men. New York: Dutton, 1996; Rotello, G., “The Twilight of AIDS?” The Nation(1996) (www.thenation.com); Scarce, M., “Life after latex.” POZ (June 1999): 92-93; Sheon,N. and Plant, A., “Protease dis-inhibitors? The gay bareback phenomenon.” HIVInSite (1997)(www.hivinsite.ucsf.edu); and Vittingoff, E., Douglas, J., Judson, F., et al., “Pre-contact risk of human immunodeficiency virus transmission between male sexual partners.” American Journal of Epidemiology 150 (1999): 306-311.
738.Nieves, E., “Privacy questions raised in cases of syphilis linked to chat room.” New York Times (August 25, 1999): A1. One controversial old approach was also revisited: In 1999 the question of reopening San Francisco's bathhouses was revived by the gay community.Coates, T. J., Acree, M., Stall, R., et al., “Men who have sex with men in public places are more likely to have unprotected anal intercourse.” Abstract # Mo.D.492. Eleventh International Conference on AIDS, Vancouver, July 1996; Elwood, W. N. and Williams, M. L., “Strategic Silence: Gay men and the use of bathhouse communication rules for unprotected anal sex.” AIDS Weekly Plus (February 8, 1999); etc..
739.Boden, D., Hurley, A., Zhang, L., et al., “HIV-1 drug resistance in newly infected individuals.” Journal of the American Medical Association 282 (1999): 1135-1141; Cohen,O. J.and Fauci, A. S., “Transmission of drug- resistant strains of HIV-1: Unfortunate, but inevitable.”Lancet 354 (1999): 697-698; Garrett, L., “New, deadly HIV?” Newsday (September 22, 1999):A3; Little, S. J., Daar, E. S., D'Aquila, R. T., et al., “Reduced antiretroviral drug susceptibility among patients with primary HIV infection.” Journal of the American Medical Association 282(1999): 1142-1149; etc..
740.曼哈顿亚伦钻石艾滋病研究中心的马丁·马科维茨博士领导了一个由纽约市和洛杉矶研究人员组成的研究小组，他们分析了平均感染时间不到两个月的77名男性和3名女性中发现的艾滋病病毒。这意味着科学家们能够从病人的血液中恢复出与他们体内携带已知突变的病毒株相同的病毒株，这些变异使抗逆转录病毒药物产生抗药性。甚至更多的患者—26.8%的患者携带的病毒能够在装满各种抗艾滋病药物的试管中生长。这意味着艾滋病病毒中存在着比科学家迄今所能确定的更多的抗药性基因类型。最关键的是，3.8%的人有多药耐药性—个体内毒株对全套鸡尾酒疗法药物的敏感性比正常人低1000倍。
马科维茨坚持说：“在任何生物体中，16%的耐药性作用都是非常显著的。不应认为耐药性的传播微不足道。”
另一个研究小组分析了129名男性和10名女性感染12个月内的病毒。这些人于1989—1998年间在圣地亚哥、洛杉矶、丹佛、达拉斯或波士顿被感染。在这个群体中，26%的人携带耐药病毒，2%的人有高度多重耐药菌株。
日内瓦大学医院研究员卢克·佩林博士在对82名新感染的法国和瑞士患者的研究基础上发表了类似的发现。记住，鸡尾酒疗法在这些国家的广泛使用时间比美国少了大约一年，有趣的是，佩林的抗药性药物库仅占这些患者的11%。但其中4.3%的人感染了艾滋病病毒，这些艾滋病病毒对最新一类药物有抗药性，而对最古老的药物齐多夫定的耐药率为9%。1998年，一名具有高度多重抗药性的艾滋病患者被感染。
佩林写道，这一发现对“鸡尾酒疗法的管理构成了严重威胁”。他主张将所有艾滋病患者的耐药性检测作为一个路径问题。
741.Centers for Disease Control and Prevention, “Monitoring Hospital-Acquired Infections to Promote Patient Safety—United States, 1990-1999.” Morbidity and Mortality Weekly Report 49 (2000): 149-153.
742.Murray, B., “Vancomycin-Resistant Enterococcal Infections.” New England Journal of Medicine 342 (2000): 710-721.
743.Centers for Disease Control and Prevention, “Staphylococcus aureus with reduced susceptibility to vancomycin—llinois, 1999.” Morbidity and Mortality Weekly Report. 48 (2000):1165-1167.
744.National Intelligence Council. “The global infections disease threat and implications for the United States.” Released on the Internet in January, 2000, at http://www.cia.gov/cia/publications/nie/report/nie99-17d.html.
745.Chemical and Biological Arms Control Institute and CSIS International Security Program, “Contagion and conflict: Health as a global security challenge.” Center for Strategic and International Studies. Washington D.C., 2000.
746.The Commonwealth Fund, “U.S. minority health: A chartbook.” New York: The Commonwealth Fund, 1999.
747.差别真的很惊人：1998年全市的死亡率是8.3/1000人。在哈林区中部，这一比例为12.3/1000人。城市心脏病死亡率为348/1000人，哈林区为359.4/1000人。癌症死亡率更高：全市每1000人中有197.4人死于癌症，而哈林区为280.6/1000人。哈林区的艾滋病病毒感染率是城市平均水平的3倍（72.7/1000人比27/1000人）。在哈林区，肺炎死亡人数几乎翻了一番（每1000人中有61.5人死于肺炎，而全市只有36.6/1000人死于肺炎）。糖尿病死亡人数增加了一倍（哈林区为42.4/1000人，全市为21.1/1000人）。
748.Senior, K., “Worrying trend in hypertension described for USA.” Lancet 354 (1999): 747.
749.Reuters, “U.S. health care can kill, study says.” San Francisco Chronicle (October 21,1997): A3.
750.Edmonson, M. B., Stoddard, J. L., Owens, L. M., “Hospital readmission with feeding related problems after early postpartum discharge of normal newborns.” Journal of the American Medical Association 278 (1997): 299-303.
751.Mays, G. P., Miller, C. A., Halverson, P. K., et al., “Performing essential public health services in the nation's most populous communities: Who contributes?” In press, 2000.
第五章
1.Fenn, E. A., “Biological warfare, circa 1750.” New York Times (April 11, 1998):A1l.
2.奥斯特霍尔姆和其他人面临的部分问题是机构内部缺乏科学的专业知识。例如，国务院实际上没有一个真正具有科学技术专长的工作人员。
1998年，克林顿总统任命肯尼思·伯纳德博士为国家安全委员会成员，这标志着第一次有科学和医学专业知识的人加入了这个重要的咨询小组。美国国家情报委员会主席约翰甘农公开向大学科学家寻求这种专门知识。例如，在1998年斯坦福大学的一次演讲中，他说：“当我看到这些杰出的听众时，在他们身上我能发现我们所需要吸引的人才，去为我国抵御日益增长的生物战威胁做出贡献。”
3.1997年9月13日，亨德森在旧金山举行的美国感染病学会会议上发表演讲。
4.A brilliant account of these events can be found in Remnick, D., Resurrection: The Struggle for a New Russia. New York: Random House, 1997.
5.Much of Henderson's thesis later appeared in print: Henderson, D. A., “Bio-terrorism as a public health threat.” Emerging Infectious Diseases 4 (1998): 488-94.
6.Henderson, D. A., “Biological terrorism.” International Conference on Emerging and Infectious Diseases. Centers for Disease Control and Prevention, Atlanta, Georgia, March 10,1998.
7.Lederberg, J., Speech to the International Conference on Emerging and Infectious Diseases, Atlanta, Georgia, March 8, 1998.
8.Lillibridge, S.,“Public health preparedness and response roles for CDC related to bioterrorism.” International Conference on Emerging and Infectious Diseases, Atlanta, Georgia,March 10, 1998.
9.这篇报道来自大量采访和纸质材料。欲了解更多详情，请读者参阅Falkenrath,R. A., Newmann, R. D., and Thayer, B. A., America's Achilles' Heel: Nuclear, Biological and Chemical Terrorism and Covert Attack. Boston: Massachusetts Institute of Technology Press,1998; Hoffman, B., Inside Terrorism. New York: Columbia University Press, 1998; Schweitzer,G. E., and Dorsch, C. C., Superterrorism: Assassins, Mobsters, and Weapons of Mass Destruction.New York: Kluwer Academic, 1998; Stern, J., The Ultimate Terrorists. Cambridge, Mass.:Harvard University Press, 1999; and Taylor, R., “All fall down.” New Scientist (May 11, 1996).New York psychiatrist Robert Jay Lifton offers a chilling account of how the Aum Shinrikyo cult members saw their mission and rationalized their deeds. From 1995 to 1997 Lift on interviewed dozens of cult members, obtaining further details not only of their actions but also of their collective psychology. See Lifton, R. J., Destroying the World to Save It: Aum Shinrikyo,Apocalyptic Violence, and the New Global Terrorism. Metropolitan Books, New York, 1999。
10.关于奥姆真理教及其活动的细节有很多来源。除访谈外，还参考了以下来源：“Congress probes Japanese cult.” Military Newswire, 1996; Henderson, D. A., 1998, op. cit;NSTC Committee on International Science and (CISET) Working Group on Emerging and Re-Emerging Infectious Diseases.“Global microbial threats in the 1990s.” The White House, 1996;“Japanese cult member gets life.” Associated Press, May 26, 1998;“Japanese guru will hear litany of nerve-gas victims.” Associated Press (April 20, 1996); Lewthwaite, G. A., “Terrorist attacks in US expected.” Baltimore Sun (November 1, 1995): A1; Morita, H., Yanagisawa, N.,Nakajima, T., et al., “Sarin poisoning in Matsumoto, Japan.” Lancet 346 (1995): 290-93;等。
11.1998年，一些当局确信奥姆真理教不仅继续存在，而且当时还在积极招募新成员。
12.一年前，1994年6月27日，奥姆真理教进行了第一次成功的袭击，在日本中部城市松本释放了沙林毒气。这一次，邪教分子在晚上释放了毒气，当时大多数松村人都在家里。那天晚上11点，毒气泄漏大约2小时后，救护车呼叫着蜂拥而至。在最初的几小时内，7人死亡，58人住院治疗，共有600人寻求治疗。伤者中有许多救援人员和消防员在4小时内赶到现场。在袭击发生3周后，大多数暴露在毒气中的幸存者仍然生病，并且在数月后脑部扫描读数异常，显示出癫痫类型的紊乱。
尽管日本当局做出了很大的努力，但还是花了三个多月的时间才确定这些死伤的化学原因。直到东京地铁袭击后，奥姆真理教才被认为是松本杀人案的罪魁祸首。
13.美国参议院顾问约翰·索普科对新科学家罗伯特·泰勒说：“奥姆基金的行为导致了非常可怕的后果，将诸如戴维支部等团体的宗教狂热、美国民兵运动的反政府议程和奇爱医生的技术诀窍都集结到了一起。
14.Offce of Technology Assessment. Technology Against Terrorism: The Federal Effort.Washington, D.C., 1993.
15.关于《禁止生物毒素和武器公约》限制的客观评论可以参阅Johnson, S. E,editor. The Niche Threat: Deterring the Use of Chemical and Biological Weapons. Washington,D.C.: National Defense University Press, 1997; Kadlec, R. P., Zelicoff, A. P., and Vrtis, A. M.,“Biological weapons control: Prospects and implications for the future.” Journal of the American Medical Association 278 (1977):351-56; MacKenzie, D., “Biological weapons treaty needs teeth.” Los Angeles Times (March 23, 1998): A11; Pearson, G. S., “The complementary role of environmental and security biological control regimes in the 21st century.” Journal of the American Medical Association 278 (1997): 369-72;等。
16.我和《新闻日报》记者蒂姆·菲尔普斯、苏珊·萨克斯、大卫·费尔斯通、罗恩·豪威尔、乔希·弗里德曼和帕特·斯洛扬等人，为《新闻日报》报道了海湾战争，斯洛扬获得普利策奖，他揭露了盟军军事行动的负面影响。这里的一些细节来自我在《新闻日报》同事们的报道。此外还有：“Memopack: The gulf crisis.” Nicosia, Cyprus: Memopacks Publishing Company, 1991; and Matar, F., Saddam Hussein: A Biography. London: Highlight,1990。
17.Matar, F., 1990, ibid (English-language edition), 59.
18.两伊战争始于1980年两国外交关系紧张时期。时任伊拉克总统的侯赛因宣布，他将单方面终止维持伊伊和平的阿尔及尔协议。在谈到伊朗领导人霍梅尼时，侯赛因宣布，伊朗人“抱有幻想，认为他可以占领这个给予他14年款待的国家。如果他愿意的话，他可以通过兄弟情谊来征服它，但他不能把他的种族主义扩展到这个国家的一丁点儿土地上。霍梅尼知道，他只能越过阿拉伯湾越过伊拉克烈士的尸体。”参见Matar, F., 1990,ibid, 135。
19.没有人真正知道在伊朗和伊拉克战争中有多少人受伤或死亡。两个政府都认为公布真实数字不符合他们的利益。文中引用的数字来自美国情报部门的估计。但这些肯定是保守的。据估计，仅伊拉尼人的死亡人数就高达100万人，其中包括所有18至30岁男子中20%的死亡人数。另有估计25万伊拉尼人死亡、10万伊拉克人死亡。伊拉克国防部声称有100万伊朗人丧生，300万人受伤致残。不管是什么情况，这个屠杀是极其可怕的。在德黑兰，它被用著名的烈士喷泉具体化了，喷泉里流淌着人类的鲜血。
20.联合国，“秘书长派往调查伊朗伊斯兰共和国和伊拉克之间冲突中使用化学武器指控的特派团的报告”。
21.Sidell, F. R. and Franz, D. R., “Overview: Defense against the effects of chemical and biological warfare agents.” In Zajtchuk, R., op. cit.
22.Manngold, T. and Goldberg, J., Plague Wars: The Terrifying Reality of Biological Warfare. New York, St. Martin's Press, 1999.
23.两起事件似乎推动伊拉克朝着生化战的方向发展。1981年，以色列空军轰炸并摧毁了伊拉克的奥西里克核反应堆，这是法国政府赠送的礼物。以色列声称，侯赛因政府在那里拥有武器级核材料并制造原子弹。以色列在这类问题上的可信度因其1990年承认其拥有一个化学武器计划而受到玷污，该计划的细节尚未公布。
有趣的是，公开记录中没有证据表明联合国剥夺了对公认的以色列化学武器的检查权，尽管使用这些武器至少会违反以色列加入的两项国际条约。此外，情报来源同意以色列拥有生物武器能力，并可能储存了一些攻击性生物制剂。但以色列从未被联合国或任何西方国家政府强迫提供其生化工作的报告或接受联合国安理会的检查。
尽管西方军事专家确信以色列的说法被夸大了，但他们当时毫不怀疑侯赛因确实在试图使伊拉克成为一个核国家。
24.George, A., “Saddam bought germ warfare chemicals in UK.” Evening Standard(London) (July 11, 1995): 23; Butcher, T., “Iraq crisis: Germ warfare ‘jelly’ sold to Iraq until 1996.” The Daily Telegraph (London) (February 19, 1998): 19; Beal, C., “How to spot a killer cloud.” New Scientist (April 8, 1995): 24; and Bone, J., “Chemical agents.” The Times (London)(December 13, 1997), Features.
25.Tucker, J. B., “Hide-and-seek, Iraqi style.” New York Times, Op Ed page (November 22, 1997).
26.Zilinskas, R. A., “Iraq's biological weapons: The past as future?” Journal of the American Medical Association 278 (1997): 418-24.
27.Regis, E., The Biology of Doom: The History of America's Secret Germ Warfare Project.New York, Henry Holt and Company, 1999.