"Three years into the Acer investigation, I had fallen deeply into a U.S. Government cover-up... [t]he Centers for Disease Control and Prevention (CDC) and Florida health officials had covered up almost all of the incriminating evidence linking Dr. Acer to thirty six serial killers studied by the FBI."
"I was forced to conclude the authorities covered up the evidence implicating Dr. Acer to prevent the media, and subsequently the public, from probing into his background. The legal testimony in the case indicated he believed he was dying of a virus that the government had created. Dr. Acer, his best friend testified, believed that the virus had been unleashed for genocide against America's gay community and Third World Blacks."
Dr. Len Horowitz
FOR three years, medical sleuths have been trying to figure out how Dr. David J. Acer, a Florida dentist, infected six of his patients with the AIDS virus. But they are stumped, and the case has become one of the most disturbing unsolved mysteries in the annals of medicine.
Now, some are asking whether it should be considered a murder mystery.
The late Dr. Acer is the only health care worker anywhere known to have infected even one of his patients. Last month, a teen-aged girl became his sixth patient to test positive for the same strain of the virus that killed him. Fifty-seven other health-care professionals have told the authorities that they are H.I.V.-positive; 19,000 of their patients have been tested. Not one has caught the virus from medical treatment.
Because of publicity about Dr. Acer and his patient Kimberly Bergalis, who died of AIDS in 1991, legislators and public health officials have come under enormous pressure to restrict infected health-care workers.
Before Miss Bergalis died at age 23, she and her family waged a crusade for laws mandating that all medical workers get AIDS tests and be forced to tell their patients if they were infected. Her father, George, argued that "someone who has AIDS and continues to practice is nothing better than a murderer."
Some groups that represent medical workers call the testing an invasion of privacy and say such disclosures would empty the practices of infected dentists and slam the operating room doors shut on infected surgeons. Now perplexed scientists are asking in public what they had only whispered before: Could Dr. Acer have done it deliberately? And if so, how? And why?
And the very asking of those questions raises another: If a convincing case can be made that Dr. Acer murdered his patients, is it fair to write restrictions on every medical and dental worker in the United States because of the actions of one lunatic?
Before he died of AIDS in 1990, Dr. Acer wrote an open letter to his patients saying: "I am a gentle man, and I would never intentionally expose anyone to this disease. I have cared for people all my life, and to infect anyone with this disease would be contrary to everything I have stood for."
The Federal General Accounting Office, which looked into the case at Congress's request, has said that "no good evidence suggests that the dentist deliberately infected his patients."
Nevertheless, with news of the latest infection, the case for murder is being argued again -- largely because there is no other plausible way to explain what happened, and growing disbelief that a dentist could have accidentally infected so many people.
The American Dental Association has not formally considered the question since there is no evidence against Dr. Acer, said its director, Dr. John S. Zapp.
But Dr. Harold W. Jaffe, an epidemiologist who headed the team that investigated the case for the Federal Centers for Disease Control, says people asking him about the case now often assume it was murder.
"You present the negative evidence," he said, "and people just shrug and say, 'That is not really evidence -- all you are really saying is you haven't found out how he could have done it.' "
He notes that the C.D.C. isn't a police agency and that Florida prosecutors have twice declined to open a criminal investigation. The Case for Calling It Murder
One dentist who believes Dr. Acer murdered his patients, and who discussed the case with colleagues at a recent meeting, is Dr. Stanley N. Turetzky, who practices in Hicksville, N.Y. "How else could it happen except by some deliberate method?" he asked in an interview. "Everybody seems to think that, but no one has proof."
A possible motive was suggested by Edward Parsons, a nurse who was a friend of Dr. Acer. He told The Palm Beach Post last year that Dr. Acer had said to him in 1988 that mainstream America was ignoring AIDS because it affected mostly homosexuals like himself, hemophiliacs and drug addicts. "When it starts affecting grandmothers and younger people, then you'll see something done," Mr. Parsons said Dr. Acer told him.
Dr. Acer knew he was infected as early as 1986. The six patients, all of whom were probably infected by mid-1988, include four women and two men ranging in age from about 15 to about 65.
There are several ways he might have infected them, accidentally or deliberately.
The initial assumption was that his equipment had blood on it, passing the virus from him to patients or from patient to patient. But the investigating team virtually ruled that out.
All the strains of the virus are the same as his.
No pattern in the dates of appointments is apparent; as far as can be told from Dr. Acer's records, no more than two of the infected patients were ever in his office on the same day. When they were, it seemed unlikely the same instruments would have been used on them.
Investigators said Dr. Acer did not always sterilize his equipment but that he was no more sloppy than other dentists in the area.
A second theory is that he accidentally cut his own finger while working and bled into his patients' mouths, or jabbed himself with a hypodermic without noticing it and injected his blood along with the anesthetic.
But that explanation has been weakened by the latest case; the teen-ager only had fillings done, something unlikely to cut a dentist's fingers. The others had extractions, crown placement or other invasive work.
Many AIDS patients suffer nerve damage in their fingers; but Dr. Acer's medical records do not show that he had.
Moreover, no infected patient or office worker recalled Dr. Acer hurting himself that way, and no one suggested that he suffered AIDS-induced dementia that would have led him to ignore injuries.
"It seems very unlikely that these patients could have been infected simply by having a drop of Dr. Acer's blood falling into their mouths," Dr. Jaffe said.
Transmission through sex or rape was ruled out -- his infected patients denied having sex with him and none were under general anesthesia.
Another possibility is that Dr. Acer used instruments on himself, say at lunchtime, then did not sterilize them. No staff member reported seeing him do so -- and the idea seems a little far-fetched. It's not easy to do dental work on oneself.
If Dr. Acer did it deliberately, he has outwitted his investigators. They cannot figure out how.
Almost certainly, he would have had to inject patients with his own blood. The Case Against
His staff said he used a fresh vial of clear-colored lidocaine -- a local anesthetic injected in the gums -- for each patient. No one noticed a reddish tinge to it. No one noticed any second hypodermics that might have contained blood or other infectious fluids. His staff said nothing in his behavior made them suspicious.
And even if he did inject blood, epidemiologists are baffled by his success rate. Health-care workers have been infected by accidental needle sticks while treating AIDS patients -- but studies have shown that only about one stick in 300 transmits the infection.
Anecdotes have been cited of some AIDS victims who were so furious at having contracted the disease that they seduced other people and then taunted that that they'd passed on the infection. But no one suggested that Dr. Acer harbored such anger. He kept his homosexuality largely secret, but that may not be surprising in a city of under 10,000 people.
And Dr. Acer's friends and colleagues said he was -- as he described himself -- a gentle man, and they could not believe he would have knowingly infected patients.
He cooperated with investigators, giving them a blood sample when asked, knowing that new molecular tests would show whether his patients had the same H.I.V. strain he did.
Some have suggested that his strain was unusually virulent or that his blood unusually full of the virus. But virulence can't be tested in fatal human infections, and tests for virus concentrations weren't performed.
In a way, the Acer case was a long time coming.
Infectious disease experts had predicted that a health worker would someday give AIDS to a patient, because it has happened with hepatitis B, a liver-damaging virus spread, like AIDS, through blood or semen.
But no one expected the example to be such an anomaly -- one dentist with six cases versus 57 professionals with no cases.
And yet, none of the doctors who have lobbied legislators and officials to stop them from restricting H.I.V.-infected workers have suggested during testimony or from convention podiums that Dr. Acer could be a murderer and should not be used as a standard to judge others by. Although "deliberate infection" was sometimes on the lists scientists drew up at meetings, it was swiftly discarded, and no expert interviewed could recall a discussion that focused on murder.
The National AIDS Commission never held a session to discuss deliberate infection. Its co-chairman, Dr. David E. Rogers, who is a critic of attempts to restrict the practice of H.I.V.-infected health workers, said he now believes the omission was a serious mistake.
"It is so unthinkable to view another health professional as doing something dastardly that I guess I shied away from it," Dr. Rogers said. "But it certainly should have been on the table. It is a perfectly logical reason for not promulgating those Draconian solutions."
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