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1
Introduction
The past four decades have witnessed unprecedented success in
controlling infectious diseases, an achievement that has created great
confidence in medicine's ability to conquer sickness. Yet in only a few
years, the epidemic of human immunodeficiency virus (HIV) and ac-
quired immune deficiency syndrome (AIDS) has shaken this confidence
and revived fears at least as old as the medieval plagues.
Indeed, the plagues and more recent pestilences offer parallels to the
AIDS epidemic that may provide some useful lessons. Bubonic plague, a
bacterial disease spread by rats and fleas, caused a succession of
epidemics throughout Europe between the fourteenth and eighteenth
centuries. The worst of these, called the Black Death, wiped out at least
one-quarter of the population of Europe (Gottfried, 1983; Zuger and
Miles, 19871. Accounts of the period describe a society grappling with
many of the same questions AIDS has provoked: tensions between
individual liberties and the public good, the responsibilities of physicians
toward their patients, and the attribution of moral meaning to biological
phenomena.
In a period closer to our own, the first decades of the twentieth century
offer syphilis as an example of an epidemic disease with features similar
to those of AIDS, the control of which raised similar questions. As Brandt
(1987) has noted, the parallels in this instance are particularly striking:
they relate to science, public health, and social values.
The limitations in our knowledge of AIDS and HIV infection and the
epidemic's lack of amenability thus far to a purely technological solution
27
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28 CONFRONTING AIDS: UPDATE 1988
mirror medicine's experience with syphilis. Paul Ehrlich discovered a
treatment for syphilis salvarsan that he hoped would be the first of an
arsenal of "magic bullets," drugs that would seek out and destroy
particular diseases. Yet even penicillin, a more effective cure, has not
eradicated the disease. When penicillin was introduced in 1943, the
incidence of syphilis was 72 cases per 100,000 people; by 1956, it had
fallen to about 4 per 100,000. By 1987, however, the incidence had risen
to 15 cases per 100,000 and continues to rise (CDC, 1988a).
Public health measures present another area for comparisons between
the two epidemics. The public health response to syphilis in the early
years of this century included what are by now familiar components:
educational programs (those of the Victorian era unabashedly stressed
chastity as contrasted with "safer sex") and screening and testing for
infection. Public health measures to combat syphilis also comprised a
dramatic campaign to close red-light districts. A crackdown in the
districts during World War I resulted in the jailing of more than 30,000
prostitutes, but this program of detention and isolation had no impact on
rates of venereal disease, which increased dramatically during the war.
Perhaps the strongest parallel between AIDS and syphilis is that they
are both sexually transmitted diseases, a characteristic that often brings
social values forcefully into play. The reality of sexually transmitted
diseases threatened the strong Victorian values of discipline and restraint
and the social sanction of sex only within marriage. Among other
manifestations of opprobrium, in those times as in our own, there arose a
distinction predicated on how the infection was obtained, a distinction
between "innocent" victims of disease (children and unknowing family
members) and others who, according to prevailing moral values, were less
deserving of sympathy and medical support (Brandt, 19871.
The similarities between the AIDS epidemic of the present and epidem-
ics of the recent past illustrate that each major epidemic of a fatal
infectious disease is not unique in human history but nevertheless is an
unusual event in its own time. Polio and smallpox are more recent
examples of feared and calamitous epidemics that were eventually
controlled by the advent of a vaccine; in the case of smallpox, a
worldwide eradication effort was also necessary. There are important
differences between AIDS and past epidemics, however, and between
AIDS and other diseases of our time that also exact a heavy human toll.
As the committee assessed problems and potential solutions in the areas
of public health, health care, research, and national leadership, a recur-
ring question emerged: Should extraordinary measures be taken in
response to the AIDS epidemic and all its ramifications, given the
magnitude and dimensions of other afflictions such as heart disease and
cancer?
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INTRODUCTION 29
The committee believes that AIDS is a special case among current
diseases. Its characteristics define a unique pattern; although it shares
particular features with other diseases, no one disease, past or present,
encompasses all the challenges posed by AIDS.
AIDS is an infectious, fatal disease for which there is now no cure. All
infected persons appear to remain infectious, both during the long
asymptomatic incubation period of HIV infection and during sympto-
matic disease. This protracted infectiousness is unusual in the history of
infectious diseases. The primary sufferers of AIDS come from what is
ordinarily a healthy and productive population group: young adults. The
Centers for Disease Control (CDC) calculate premature mortality in the
United States according to total years of potential life lost before age 65.
Against a backdrop of overall decline in years of potential life lost, AIDS
has moved from 13th in 1984 to the 8th leading cause of premature
mortality in 1986 (CDC, 1988b). The absolute mortality caused by AIDS
to date may be exceeded by other major diseases, but the steep slope of
its rise and the youth of its victims are unmatched.
Because AIDS first occurred in the United States among already
stigmatized groups homosexual and bisexual men and intravenous (IV)
drug abusers the social response to it has been complicated by moral-
istic assignments of blame for vulnerability to the disease, much as in
earlier days when plague was seen as divine retribution. The persistent
fear of casual transmission, in the face of mounting evidence to the
contrary, is reminiscent of theories that syphilis was transmitted by toilet
seats, pens, and doorknobs, beliefs that lingered well past the time when
scientific evidence had proven them groundless. These social construc-
tions of disease, and the fertile ground they provide for restrictive or
discriminatory social responses, also set AIDS apart as a matter for
special concern. The way in which traditional public health responses are
complicated by these features of AIDS is discussed in Chapter 4.
There are other aspects of the AIDS epidemic that set it apart. A
disproportionate burden in the care of AIDS patients falls on certain
geographic locations where the prevalence of infection is high. In fact, the
AIDS epidemic is really a series of discrete epidemics in particular
population subgroups in particular places. Society was unprepared for the
numbers of patients generated by infection with HIV. Furthermore, the
AIDS caseload began to mushroom at a time when hospital beds were
being eliminated. If a business-as-usual approach is taken, one conse-
quence of the epidemic may be the decline of hospitals and health care
systems in high-prevalence areas. (This aspect of the epidemic is dis-
cussed in Chapter 5.) The fundamental uncertainty about the epidem-
ic's future course (see Chapter 3), in contrast to other conditions such as
heart disease or cancer for which the burden of illness is more predict-
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30 CONFRONTING AIDS: UPDATE 1988
able, lends urgency to the need for attention. In addition, the international
spread of the disease brings special responsibilities to the United States
(see Chapter 7) because of our exceptional resources in public health and
biomedical personnel, the large numbers of infected persons in the United
States, and our relative affluence.
A further compelling argument for now focusing special attention on
AIDS is that future HIV infections are preventable by modifying the
behavior that brings individuals into contact with the virus. IV drug abuse
and sexual behavior may be both biologically and socially based and are
not always voluntary in the simplest sense. Yet the potential exists for
their modification through education, counseling, and treatment. In
addition, increasingly detailed epidemiological knowledge about the
modes of spread of the disease constitutes a firm foundation of data on
which to construct public health programs responsive to the precise
contours of the epidemic (Osborn, 19884. We may be in the midst of a
disaster, but we also have the means to avert future devastation.
Whenever a system is brought into play to cope with AIDS be it a
social, biomedical research, or medical care system—its deficiencies are
exposed. (A few examples are the financing of care, the organization of
medical services, foster care, the availability of drug abuse treatment, and
the coordination of research efforts.) Once AIDS is considered a special
case, however, a broader range of solutions to the problems posed by the
AIDS crisis opens up. There are three viable categories of approaches: (1)
strengthening programs within the context of existing systems; (2) devel-
oping new schemes that resolve general problems brought into focus by
AIDS; and (3) formulating AIDS-specific solutions (this kind of specific
response is often fragmented from the system as a whole, but its
advantage is that it can be quickly deployed to respond to an emergency).
With these approaches in mind, the committee has tried to lay out a
number of options in making recommendations for further action against
the AIDS epidemic.
The committee is aware of the possible dangers in granting any one
disease special status in particular, that attention and resources might
be diverted from other important conditions. In shaping its recommenda-
tions, the committee took particular care to advise against such diversion.
Furthermore, just as the results of our experience with other diseases
(e.g., cancer) have equipped us to address the challenge of HIV infection
and AIDS, so will solutions to the AIDS crisis produce benefits in diverse
and possibly unforeseen areas that may well be applicable to other
illnesses. These areas include basic science, drug and vaccine develop-
ment, the financing of health care, alternative health care settings,
knowledge of human behavior, relationships between health care provid-
ers and patients, drug abuse prevention and treatment, and compassion-
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INTRODUCTION 3 1
ate treatment of the sick and disabled. Rather than overshadowing efforts
in other fields, considering AIDS a special case may illuminate new
directions in the management of other illnesses.
REFERENCES
Brandt, A. M. 1987. No Magic Bullet: A Social History of Venereal Disease in the United
States Since 1880. New York: Oxford University Press.
CDC (Centers for Disease Control). 1988a. Continuing increase in infectious syphilis-
United States. Morbid. Mortal. Wkly. Rep. 37:35-38.
CDC. 1988b. Quarterly report to the Domestic Policy Council on the prevalence and rate of
spread of HIV and AIDS in the United States. Morbid. Mortal. Wkly. Rep. 37:223-226.
Gottfried, R. S. 1983. The Black Death. New York: Free Press.
Osborn, J. 1988. AIDS: Politics and science. N. Engl. J. Med. 318:444-447.
Zuger, A., and S. H. Miles. 1987. Physicians, AIDS, and occupational risk. Historic
traditions and ethical obligations. J. Am. Med. Assoc. 258:1924-1928.
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Representative terms from entire chapter:
drug abuse
