A doctor's take on Dallas Buyers Club

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Oscar nominations are out and Dallas Buyers Club is up for six Academy Awards including Best Picture. 

The movie is about Ron Woodroof (Matthew McConaughey), a heterosexual male who is unexpectedly diagnosed with AIDS in 1985. Woodroof soon realizes that certain medications and supplements from Mexico are better at relieving his symptoms than AZT, the only FDA-approved drug available for HIV treatment in the U.S. at the time. He then begins smuggling these unapproved pharmaceuticals into the United States and selling them with the help of Rayon (Jared Leto), an HIV positive transsexual. It's a movie that provides an interesting look into the early days of HIV/AIDS treatment and the discrimination that many HIV positive people faced at the time. 

If you have any interest in medicine at all, I highly recommend you watch the movie. If not, watch it anyways. It deals with a topic that is still very relevant today. Plus Matthew McConaughey and Jared Leto both give Oscar worthy performances. 

To get additional insight into some of the events and perspectives depicted in the movie, I interviewed Dr. Mark Katz. Dr. Katz is one of my mentors in medical school and has extensive experience treating HIV and AIDS patients throughout the outbreak of the 1980s. He is also a regional HIV/AIDS physician advisor at Kaiser Permanente. 

Spoilers ahead! Beware. 

What was your initial impression of the movie?

The first time I made the mistake of seeing it when I was tired. There was something that happened at the beginning of the movie that was very medically inaccurate and it turned me off to the movie. The second time I saw it, I was much more forgiving.

At the beginning of the movie, Ron Woodroof is taken to Dallas Mercy Hospital after losing consciousness. There is he told by doctors that he has tested positive for HIV and has around 30 days to live. What happened during that scene that initially “turned you off” to the movie?

You then, and even now, do not test without someone’s consent. So they made a huge [error] in that.

[The scene] took place in July 1985 and the test had come out in March of 1985. This is a little more personal to me but the first year that the test was out it took two weeks to get your results. I felt like the movie was almost disrespectful, I mean it wasn’t malicious, but for all the people like myself who had to go through the period of gearing up to getting testing and then waiting those two weeks and then going into a room, a cold room, where a counselor walks in and then gave you your results. The movie just ignored all that and I’m not sure with all the brilliance in Hollywood why they couldn’t have made that a part of the plot.

Also they told them that he had like nine T-cells. There’s no lab in the world, no emergency room, that counts T-cells on the spot like that.

So they compressed this whole story into this one scene and as an emotional person who lived through all this, it felt almost disrespectful.

On the movie’s general depiction of AIDS:

It wasn’t as accurate in showing the fact that people who died of HIV, they did not just die of AZT, which is questionable whether they did or not, they died of opportunistic infections. Nobody in the movie had pneumocystis pneumonia that we saw. You did see [Rayon] have a Kaposi’s sarcoma lesion at the end before he died. People who had KS were usually riddled; I saw people whose faces were all purple, it was that horrendous.

On the movie’s portrayal of the social issues affecting HIV patients at the time:

I thought it captured the spirit and the amazing discrimination at that time. The scene where [Ron Woodroof] forces one of the characters to touch [Rayon’s] hand or when [Ron] goes back to his house and sees “Faggot Blood” written on the door or the way his circle of friends changed. All of that was very accurate and poignant. I though the movie did a wonderful job of capturing a horrible time in the lives of people with HIV.

Even in the gay community, many people who were HIV negative would not connect with those that were positive. There was paranoia and fear within the gay community surrounding dating in the mid 1980s and whether someone had gotten tested. A lot of people wouldn’t kiss or touch. …There were many questions about saliva and oral transmission.

What did you think about Dr. Eve Saks (Jennifer Garner) and her growing friendship with Woodroof in the movie?

Something the movie captured well, which I lived through, was the way the physicians were portrayed. I thought that Jennifer Garner’s character, the way that she was first the researcher and clinician and then how she completely crossed over to the other side as an advocate, was very well done. I think that movie was also very careful to not show anything that was clearly inappropriate.

In those days, Dr. Gary Cohan published an article called “Wearing Two Hats” in the Advocate. It was about the notion that as a clinician, he took care of people with HIV and as an openly gay man in his thirties, he went to parties and knew people who were in this same situation. They became his friends to some extent. So I experienced that too. I have always had pretty tight boundaries with patients but in the HIV arena, some of that gets broken down a little bit. I think there is whole middle ground. The fact that they showed [a doctor, Jennifer Garner] doing that was actually pretty well depicted. It happened a lot in those days.

The physicians became the allies of the patients. Many physicians, myself included, participated in marches and activities against the FDA and drug companies. It wasn’t just the people with HIV against the whole system.

AZT was criticized and its efficacy questioned throughout the movie. From a physician’s perspective, what were your thoughts on that?

It was a little too heavily anti-AZT in my opinion. I remember the buyers clubs at the time and there was a sense of extremism in these buyers clubs. There was a sense that all medication was going to kill people. And AZT didn’t do that. I remember that after AZT was approved in March 1987, there were people who gained 20-30 pounds and stopped wasting and their symptoms disappeared. Of course what we learned later about AZT was that any single anti-viral will eventually cause resistance so one drug wasn’t enough.

Woodroof advocates for the use of the unapproved drug DDC over AZT in the movie.

Paradoxically, DDC wound up becoming FDA approved and it’s never prescribed anymore because it can cause severe neuropathy and pancreatitis. It was actually deemed to be fairly toxic.

On the character of Rayon and Jared Leto’s performance:

He was fantastic. That is the Oscar sewn up. It though it was really realistic. I thought [Rayon’s] death was a little fast. In the real world, he would have had an opportunistic infections or something would have happened.

Still, I thought it brought up the idea of people with a limited time left wanting to be themselves as much as possible. It certainly brought up the issue of the concurrence of substance use and how that manifested in the epidemic.

On how the medical community first dealt with HIV/AIDS in the early days of the epidemic:

The movie can’t do everything but if I were doing a critical review of it, the movie did not emphasize enough how caught with our pants down the medical profession was. We just didn’t know what to do, particularly before AZT. Up till 1982, there were only about 26 cases of mycobacterium avium (MAC) infection in the world literature. If you walked into an AIDS practice in Los Angeles only 5 years later, in 1987, there would be ten people in a day coming in with MAC infection. In such a short period of time had to deal with something we knew so little about.

On what makes HIV such a unique disease:

People always ask why is HIV different than diseases like diabetes or cancer or asthma, which are all conditions that affect many more people. As a medical student or a nurse or a doctor, you don’t go to work everyday afraid you are going to catch breast cancer. But there was a real palpable fear, particularly among surgeons through the 1980s and 90s, that they would become infected with HIV.

I thought the first [scene in the movie] where the doctors were all wearing masks and gloves was terrific but I wish they had carried that out more.

What did you think about Dr. Saks’ actions when Ron asks her for prescriptions to drugs he wanted to sell?

I thought Eve Saks was actually depicted pretty well. Her character really brought out the connections physicians had with their patients and how they tried to help them but still within legal bounds.  

We were asked all the time for sleeping pills. There was a cocktail that was going around that a physician in San Francisco popularized that many people who committed suicide used. And I would have patients ask me for some of those drugs. They didn’t ask me for 400 of them but they would ask me for 10-15 and then ask for 10-15 more later. There was a subtext that you knew what was going on. But there is a difference between understanding that the patient wanted a little control over their death and being Jack Kevorkian. No one that I knew actively participated in [patient] suicide but a lot of people knew about it. It was a pretty dismal existence. With AIDS and people being depressed about their life ending, they were right. So I saw that happen a lot.