Susan Orlean’s The Library Book was published by Simon & Schuster in 2018 to universally enthusiastic and laudatory reviews—including one in “America’s LGBTQ news source,” the Washington Blade. Although it largely deserves the praise it’s received, it also contains errors that should never have survived careful editing and fact-checking.
If you love books, if you like to read, then you should like this book. It’s a book about books, or, more broadly, a public library—the Los Angeles Public Library—as an information system, a community resource, and a reflection and integral part of the society in which it functions. At the same time, because it focuses on the fire that destroyed much of the Los Angeles Central Library in 1986, it is also a true crime whodunit.
Orlean is a real pro. The opening pages of The Library Book are a model of how to start a compelling nonfiction narrative for a general readership. And one of Orlean’s skills as a writer is her ability to put herself into the story, and her accounts of her own experiences with books and libraries animate this book. She strikes me as the sort of person who would be a great dinner party guest.
But despite her formidable skills and varied interests, we see here how challenging it is to write nonfiction—and how far wrong an author can go in just three sentences.
The Creation of an AIDS Villain
Orlean gets into trouble when describes her interview with the Los Angeles Central Library’s security chief, David Aguirre, as she accompanied him on his rounds through the library. She doesn’t directly quote him as the source, but she provides this account of an incident at the library:
Working the library [security] detail is generally benign, although a few years ago, an agitated man stabbed an officer with a needle. The man had HIV/AIDS, so he was charged with attempted murder. The officer never contracted the disease but will have to be tested for years.1
As I’ll explain, this brief passage exaggerates the risk of HIV transmission and the resulting harm, but it also displays a seemingly complete lack of knowledge about current HIV testing and treatment. It’s as though the scenario she’s described happened not “a few years ago,” but more than 30 years ago.
Not only does Orlean get the facts wrong, but she’s reanimated the AIDS villain trope—a “germ-panic” scenario in which someone with HIV seeks to kill by “intentionally transmitting AIDS.” Now, almost 40 years into the AIDS pandemic, an AIDS villain emerges once again.
I’m not suggesting that the stabbing incident didn’t take place, or that it wouldn’t have been traumatic and distressing for the security officer—perhaps profoundly and unnecessarily so, if they were given inaccurate information about the risk of HIV transmission from such an injury. More about that later.
My point is that Orlean’s telling of it is misleading and factually incorrect—perpetuating fearful misunderstandings about HIV and, at the same time, stigmatizing people with HIV. What’s misleading about it is the way in which the story is told in such an uncritical way, leaving the reader simply to accept the story as the truth.
Consider, too, that the stigma here goes beyond HIV status. The man with HIV is not acting out of anger or some provocation—he is “agitated.” This is code, I think, to say that he is living with a mental illness. Because the weapon is a “needle”—the context implies that it is or was used to inject drugs—the implication is that he is also living with an addiction to drugs. Like HIV disease, mental illness and substance use disorder are chronic, treatable health conditions. But health care is not mentioned as a means of preventing or addressing this incident. Instead, this man, even though his blameworthiness is far from clear, gets the “go directly to jail” card.
These AIDS villain narratives tap into our deeply held fears of contamination with a mysterious yet deadly pathogen. They rely, in large part, on an exaggeration about risk and harm that can only heighten our feelings of vulnerability and helplessness about a peril that is poorly understood.
Among the most notorious instances of this theme is Randy Shilts’s now-discredited “Patient Zero” account in his 1987 book about the AIDS epidemic, And the Band Played On. Shilts described how flight attendant Gaetan Dugas, knowing he had AIDS, intentionally or recklessly infected numerous of his sexual partners and thus introduced HIV to cities such as Los Angeles. This narrative, however, was later exposed as a myth.
But the Patient Zero narrative—with its sensational treatment of Dugas’s alleged villainy—was what would sell books.
Exaggerating the Harm
Orlean’s account of the stabbing provides no details about the incident itself, but she didn’t have to. The reference to the resulting criminal charge of attempted murder clues the reader in to how serious this is—it was an attempt to kill the security officer. It’s clear that it’s solely because of HIV that the needle stabbing story is being told. The needle with HIV, in this scenario, is imagined to be the equivalent of a loaded gun.
That loaded gun analogy makes sense only if you’re thinking of HIV infection as a “death sentence”—something that will inevitably cause death. Indeed, Orlean, in a Paris Review interview, refers to AIDS in the early years of the epidemic as “an absolute death sentence.”
Mortality rates for people with HIV were higher in the early years of the epidemic, but it strikes me as a very unfortunate exaggeration—albeit a popular one in the news media—to equate HIV infection with a death sentence. After all, there have always been long-term survivors or “non-progressors”—estimated at somewhere under five percent of those infected—who have HIV but who, without undergoing any treatment, do not experience symptomatic HIV illness.
But putting those non-progressors aside, effective HIV treatment has been available for about 25 years. As a result, HIV is a chronic, long-term illness, with the life expectancy of those with HIV and on antiretroviral therapy approaching that of people living without HIV. HIV infection is a serious illness, no question about it, but infection does not invariably result in death. To analogize HIV to a loaded gun, even by implication, is wildly misleading.
Exaggerating the Risk of Transmission
Referencing the “attempted murder” charge might also suggest to many readers that using a needle to stab someone is a sure way of infecting them. Indeed, there is a grain of truth underlying Orlean’s account: HIV can be transmitted by needlestick injuries.
People should be aware that using needles, syringes, or drug injection equipment previously used by an HIV-infected person is a leading means of HIV transmission. Transmission occurs when HIV-infected blood in the used drug equipment is then injected into the subsequent user. Although it’s among the most common ways HIV is transmitted, it is hardly a sure thing: the Center for Disease Control and Prevention estimates that each time a needle, previously used by someone with HIV, is used by someone who is not infected to inject drugs, there is a 1 in 160 chance of transmission.
We don’t seem to have any data on needlestick transmission of HIV to law enforcement or security personnel. I suspect that not only are such incidents exceedingly rare, that’s also not how HIV is transmitted. It just doesn’t happen, so there’s no data to be collected. Workplace safety standards for HIV require, among other things, maintenance of injury logs, but those standards apply only to workers whose job duties involve “reasonably anticipated” subcutaneous contact with blood or other potentially infectious materials. That’s not library security personnel—it’s certain healthcare workers.
Looking to the health care setting, the average risk of HIV infection after needlestick injury involving HIV-infected blood is estimated to be 0.3 percent—far less than the risk from shared drug equipment. That frequently cited estimate is nothing new; it’s been around since at least 1997. In fact, during the past two decades, there has been only one confirmed case of HIV transmission by a needlestick injury. That case, from 2008, involved a lab technician who suffered a needle puncture wound while working with live HIV culture. As Orlean writes elsewhere in the book, “It is possible for health care workers to acquire HIV accidentally, but it’s rare.”2
For HIV transmission to have occurred, the injury must involve a puncture wound sufficient to transmit blood from the infected person to the officer. A tussle in which an officer is merely scratched, for example, would not pose a risk of transmission. There are a variety of unknown variables here, such as whether the needle was attached to a syringe, whether there was blood in the syringe/needle, whether the wound was deep or superficial, and whether the wound was immediately cleaned and disinfected.
Perhaps the most significant variable involving risk of HIV transmission is whether the person with HIV was taking antiretroviral medication that would reduce their level of HIV. If so, the degree of viral suppression may further reduce the risk of transmission.
For the security officer, one option, if there is concern that the injury had a non-negligible risk of HIV transmission, is to start post-exposure prophylaxis (PEP)—a four-week course of anti-retroviral treatment that will prevent infection, assuming actual exposure to HIV occurred. This treatment should be started within 72 hours (3 days) after exposure, but sooner is better.
Consistent with the idea that HIV transmission risk is exceptionally low and thus didn’t occur in this scenario, Orlean writes that “the officer never contracted the disease.” This is not as clear as it could be, but I think she means that the officer was not infected with HIV. I don’t think this means that the officer was infected with HIV, but never developed any disease symptoms.
Orlean then makes what is perhaps her most egregious error when she asserts that the officer “will have to be tested for years.” This is nonsense.
There is a window period after a potential exposure during which a negative HIV test is inconclusive as to whether transmission has occurred. The window period can vary, depending on what test is used. A nucleic acid test, for example, can tell you if you have HIV infection 10 to 33 days after exposure. But certainly after 90 days—at the latest—testing can determine whether the security officer was infected. This period of uncertainty could be a significant burden for that officer, but it’s not as though it would continue for some period of years. In Orlean’s account, even if you somehow initially survive the AIDS villain’s attack, the curse will still follow you for years to come.
A Failure in AIDS Education?
I had several reactions when I read about the stabbing incident. First, we’ve really failed in our AIDS education efforts. Perhaps this is because of the power of these almost mythic ideas about HIV transmission risk and how deep-seated our fears are. At the same time, I also wonder if AIDS is now widely thought of as a kind of non-issue, something that is of concern to some other “at risk” people, but not something of concern to the “general population” that Orlean thinks of as her readers. And not something we need to fact-check very carefully.
I don’t think Orlean has any overt antipathy for people with HIV. She writes about HIV in an uninformed way, yet she writes with compassion about people with AIDS, such as Harry Peak, the prime suspect in the Central Library arson case. She refers to Rock Hudson and Magic Johnson as LA celebrities with HIV. So it’s not that she has ignored the epidemic. That’s what makes this lapse even more disappointing and perplexing.
But I also think that this sort of error is not so easily excused. After all, it was not just Orlean, but her fact-checker and who knows how many editors at Simon & Schuster who didn’t question the anecdote. These “facts” are so easily checked just by visiting a handful of trustworthy websites (I’ve provided links to just some of them in this essay). Also, the Center for HIV Law and Policy, through its Positive Justice Project, has addressed the injustice involved in HIV criminalization in a series of publications that pre-date The Library Book. That’s just one of the many advocacy groups providing valuable guidance on criminal law and HIV.
Missing A Bigger Public Health Issue
Throughout the AIDS epidemic there have been reports of people with HIV involved in various assaultive behaviors—using needles, or spitting, or biting. Such incidents are extraordinarily rare, and as we’ve seen with the library security officer, do not result in transmission of HIV. Typically, however, people with HIV who do these things are treated harshly—unjustifiably so—in the criminal courts.
But I’ll give you a far more pertinent and lethal threat of harm faced by all of us, library personnel included. In 2016, presumably while Orlean was at work on her book, gun violence was estimated to claim 30,000 lives annually. And in 2017, in a public library in Clovis, New Mexico, a teenager used a handgun to shoot and kill two librarians and wound four others.
Referencing this shooting at the Clovis-Carver Public Library would have proven apt. Just after The Library Book was published, a librarian was shot and killed by a man whom she had previously barred from the North Natomas Public Library (Sacramento, California) because of his violent behavior.
Gun violence is a genuine public health problem and has had a direct impact on both librarians and patrons, as these tragic cases illustrate. Obviously, security personnel are often on the front lines in such confrontations. Adequate gun safety measures, which we still don’t have on a national level, would very likely have prevented them. (As I write this, President Biden just signed into law the first federal gun safety legislation in decades—a bipartisan compromise that is less stringent than what gun safety advocates had supported.) By being distracted by an AIDS villain narrative, Orlean missed an opportunity to focus on a far more lethal issue.
In 2019, the LA Times reported that Orlean was at work on an adaptation of The Library Book for television. I’m hoping the needle-stabbing story is not part of it.
In part 2 of this essay, I explore some other fact-check issues with Orlean’s The Library Book:
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Page 245. Page references are to the 2018 first edition of The Library Book as well as the 2019 paperback edition.
Page 305.