History and Geography

In its first decade, AIDS has created considerable suffering and has generated an ongoing worldwide health crisis. During this brief period, the epidemic has been identified and characterized epidemio-logically, the basic modes of transmission have been specified, a causal organism has been isolated, and effective tests for the presence of infection have been developed. In spite of this remarkable progress, which required the application of sophisticated epidemiological, clinical, and scientific research, the barriers to controlling AIDS are imposing and relate to the most complex biomedical and political questions. AIDS has already sorely tested the capabilities of research, clinical, and public health institutions throughout the world.

Because HIV is related to other recently isolated primate retroviruses such as simian T lymphotropic virus (STLV)-III, which has been isolated in wild African green monkeys, there has been considerable speculation that HIV originated in Africa. Antibodies to HIV were discovered in stored blood in Zaire dating back to 1959, and it seems likely that evidence of the organism will be identified in even earlier specimens. According to Robert Gallo and Luc Montagnier, who have been credited with the identification of HIV, it is likely that the virus has been present for many years in isolated groups in central Africa. Because outside contacts were minimal, the virus was rarely spread, and an epidemic could not be sustained. Once a sizable reservoir of infection was established, however, HIV became pandemic. As with other sexually transmitted diseases, such as syphilis, no country wished to be associated with the stigma of the "origin" of the virus.

The epidemic began at a moment of relative complacency, especially in the developed world, concerning epidemic infectious disease. Not since the influenza epidemic of 1918-20 had an epidemic appeared with such devastating potential. The Western, developed world had experienced a health transition from the predominance of infectious to chronic disease and had come to focus its resources and attention on systemic, noninfectious diseases. Thus AIDS appeared at a historical moment in which there was little social or political experience in confronting a public health crisis of this dimension. The epidemic fractured a widely held belief in medical security.

Not surprisingly, early sociopolitical responses were characterized by denial. Early theories, when few cases had been reported, centered on identifying particular aspects of "fast track" gay sexual culture that might explain the outbreak of cases of immune-compromised men. Additional cases among individuals who had received blood transfusions or blood products, however, soon led the U.S. Centers for Disease Control to the conclusion that an infectious agent was the likely link among these individuals. Nevertheless, in the earliest years of the epidemic, few wished to confront openly the possibility of spread beyond these specified "high-risk" groups. During this period, when federal and state interest and funding lagged, grassroots organizations, especially in the homosexual community, were created to meet the growing needs for education, counseling, patient services, and in some instances, clinical research. Agencies such as the Gay Men's Health Crisis, founded in New York City in 1982, and the Shanti Project, established in San Francisco in 1983, worked to overcome the denial, prejudice, and bureaucratic inertia that limited governmental response.

As the nature and extent of the epidemic became clearer, however, hysteria sometimes replaced denial. Because the disease was so powerfully associated with behaviors characteristically identified as either immoral or illegal (or both), the stigma of those infected was heightened. Victims of disease were often divided into categories: those who acquired their infections through transfusions or perinatally, the "innocent victims"; and those who engaged in high-risk, morally condemnable behaviors, the "guilty perpetrators" of disease. Since the early recognition of behavioral risks for infection, there has been a ten dency to blame those who became infected through drug use or homosexuality, behaviors viewed as "voluntary." Some religious groups in the United States and elsewhere saw the epidemic as an occasion to reiterate particular moral views about sexual behavior, drug use, sin, and disease. AIDS was viewed as "proof" of a certain moral order.

People with AIDS have been subjected to a range of discriminatory behavior including loss of job, housing, and insurance. Since the onset of the epidemic, incidents of violence against gays in the United States have risen. Despite the well-documented modes of HIV transmission, fears of casual transmission persist. In some communities, parents protested when HIV-infected schoolchildren were permitted to attend school. In one instance, a family with an HIV-infected child was driven from a town by having their home burned down.

By 1983, as the potential ramifications of the epidemic became evident, national and international scientific and public health institutions began to mobilize. In the United States, congressional appropriations for research and education began to rise significantly. The National Academy of Sciences issued a consensus report on the epidemic in 1986. A presidential commission held public hearings and eventually issued a report calling for protection of people with AIDS against discrimination and a more extensive federal commitment to drug treatment. The World Health Organization established a Global Program on AIDS in 1986 to coordinate international efforts in epidemiological surveillance, education, prevention, and research.

Despite the growing recognition of the significance of the epidemic, considerable debate continues regarding the most effective public health responses to the epidemic. Although some nations such as Cuba have experimented with programs mandating the isolation of HIV-infected individuals, the World Health Organization has lobbied against the use of coercive measures in response to the epidemic. Given the lifelong nature of HIV infection, effective isolation would require lifetime incarceration. With the available variety of less restrictive measures to control the spread of infection, most nations have rejected quarantine as both unduly coercive and unlikely to achieve control, given current estimates of prevalence. Traditional public health approaches to communicable disease including contact tracing and mandatory treatment have less potential to control infection because there are currently no means of rendering an infected individual noninfectious.

Because biomedical technologies to prevent trans mission appear to be some years away, the principal public health approaches to controlling the pandemic rest upon education and behavior modification. Heightened awareness of the dangers of unprotected anal intercourse among gay men, for example, has led to a significant decline in new infections among this population. Nevertheless, as many public health officials have been quick to note, encouraging the modification of risk behaviors, especially those relating to sexuality and drug use, present no simple task, even in the face of a dread disease.

The burden of AIDS, in both human suffering and its demands on resources, is likely to grow in the years ahead. Projections now estimate expenditures totaling nearly $70 billion per year in the United States by 1991. Ensuring quality care for those infected will become even more difficult, especially in the epidemic's epicenters, where those infected are increasingly among the minorities and poor. In the developing world, AIDS threatens to reverse advances in infant and child survival in recent decades. The epidemic is likely to have a substantial impact on demographic patterns. Because the disease principally affects young and middle-aged adults, 20 to 49 years of age, it has already had tragic social and cultural repercussions. Transmitted both horizontally (via sexual contact) and vertically (from mother to infant), the epidemic has the potential to depress the growth rate of human populations, especially in areas of the developing world. In this respect, the disease could destabilize the work force and depress local economies.

AIDS has clearly demonstrated the complex relationship of biological and behavioral forces in determining patterns of health and disease. Altering the course of the epidemic by human design has already proved to be no easy matter. The lifelong infectiousness of carriers; the private, biopsychosocial nature of sexual behavior and drug use; and the fact that those at greatest risk are already stigmatized - all have made effective public policy interventions even more difficult. Finally, the very nature of the virus itself - its complex and mutagenic nature - makes a short-term technological breakthrough unlikely.

The remarkable progress in understanding AIDS is testimony to the sophistication of contemporary bioscience; the epidemic, however, is also a sobering reminder of the limits of that very biotechnology. Any historical assessment of the AIDS epidemic must be considered provisionary. Nevertheless, it already has become clear that this epidemic has forced the world to confront a new set of biological imperatives.

Allan M. Brandt


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