November 10, 2011

AIDS and Ancient Ideas about Disease

In my class on Health and Disease in Ancient Populations this semester, I talk frequently about the epidemiological transitions - the times when people started coalescing into cities and increasing their risk of disease, then realizing that hygiene was important and began curbing disease, and finally where degenerative diseases and long-term issues are the major killers.  We've made it through the third epidemiological transition - most people are felled by heart disease and cancer, not infection.  But this epidemiological transition also means that some old diseases are returning and becoming antibiotic resistant (like tuberculosis), and new diseases are arising, like AIDS.

In talking to my class about disease among ancient populations, I also explain that, before germ theory, people didn't understand how disease was spread.  Lots of strange explanations arose.  The Romans thought that "black bile" caused cancer, for example, and the medieval Italians said that "bad air" (mal aria) could lead to disease.  We marvel at how silly these people were and how advanced our understanding of disease is through modern medicine.

Today, I came across this excellent 2006 New York Magazine timeline of the history of AIDS and had to share some of the highlights.  My first memory of AIDS was the media coverage of the illness and death of Ryan White in 1990, and then the discovery that Magic Johnson was HIV positive in 1991.  I was a teenager and assumed that doctors had it all figured out.  The timeline is truly eye-opening (really, you should go read the whole thing right now), particularly in the 1980s.  It shows how little we knew about a brand-new disease, how certain populations were blamed for its origin and spread, how medical professionals ignored symptoms because of preconceived notions of how the disease worked.  Some of the 80s entries show just how far we've come in understanding HIV and AIDS:

  • October 31, 1980. French-Canadian flight attendant Gaetan Dugas pays his first known visit to New York City bathhouses. All of the city’s early infections would be traced to Dugas, since dubbed “Patient Zero.”
  • January 1982. “Gay-related immune deficiency” (GRID) gains currency, though the name becomes obsolete when straight Haitians show up with symptoms in Brooklyn hospitals. (Hemophiliacs would soon join them in the public’s mind as the third H group seen to be at any real risk.)
  • December 1982. Dr. Arye Rubinstein submits a study to the American Academy of Pediatrics finding evidence of AIDS among five infants in the Bronx. It’s rejected—based on the belief that the disease is confined to gay men.
  • September 9, 1985. Queens parents launch a school boycott after the city allows a second-grader with AIDS to attend classes.
  • September 29, 1986. Early results show that the drug AZT can slow down progress of HIV. Jubilation breaks out—prematurely. “After six years of having nothing to do for people but hold their hands and watch them die, I got my patients on it ASAP,” recalls Dr. Howard Grossman. “We didn’t know that AZT on its own is only good for six months before resistance sets in.”
  • June 2, 1987. Mayor Koch calls for mandatory HIV testing for visitors and immigrants to the U.S. Those with HIV should be denied entry, he says.
  • January 1988. Cosmopolitan magazine says women can have unprotected sex with an HIV-positive man without fear. “Most heterosexuals are not at risk,” the magazine says, adding that it’s impossible to transmit HIV in the “missionary position."
It's stunning how little was known about this new disease, and yet, even with the knowledge doctors have gained over the last 30 years, people around the world are still ignorant of HIV/AIDS.  In 2006, South African ex-deputy president Jacob Zuma, for instance, reported that he showered after sex with an HIV-positive woman so that he wouldn't contract the disease. On the other hand, this recent LiveScience piece on Magic Johnson does a good job of explaining how the former basketball player has survived for 20 years in spite of being given what many people at the time thought was a death sentence.

AIDS education has a long way to go, but we have already started to look back on our early, flawed understanding of the disease.  The 2006 New York Magazine timeline shows that thirty years ago, we were no smarter than people who blamed syphilis on the disenfranchised and foreign or people who thought that malaria was caused by bad air.  Fortunately, it has only taken us a couple decades rather than a couple millennia to learn how to manage and cure most modern diseases.




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7 comments:

Michelle said...

This was a very interesting subject to read about; I teach college-level introductory writing courses, and had been accumulating articles to incorporate into my classes next semester, when the semester-long subject will be ethics and medicine, with an emphasis on how the ethics of medicine has changed throughout history. Thanks for posting!

Anonymous said...

From Chris Morley

Hi Kristina
Neat post and a well spotted connection / example.

However if you decide to mention HIV as an example of epidemiological transitions in your classes, you definitely need a better understanding of HIV, and alternative sources to the "AIDS in New York: A Biography" feature in New York magazine that you recommend.

I'm 60, a gay man in England, who has been active in the gay community on HIV and have closely followed and campaigned around HIV since the early 1980s, and have worked as a community sector HIV policy and practice expert since 1995.

The 'New York' article does, pretty well, *only* what it says in the title - it's a New York HIV history.

It misses out a lot of context, is myopic and omits important wider USA perspectives (e.g. San Francisco was right up with NY in the early 80s developments), and ignores the illuminating global context for a full epidemiological transitions class / study.

It doesn't provide someone who knows relatively little about HIV with several key pieces of information (epidemiology, the stages and history of the development of HIV infection in an individual, information on modern effective HIV treatments, the significance of regular monitoring of key HIV disease progress markers: CD4 count, Viral Load, etc).

I would say that the key factor omitted from an epidemiological transitions perspective is the cultural context: HIV was first spotted in NY among gay men.

And most significantly, the major contributor to HIV's early proliferation and spread was homophobia and callous indifference among city, State and federal agencies. If HIV had been a new disease among white heterosexual middle class people in the city, the response would have been completely different.

HIV can be characterised as a disease of social marginalisation and exclusion. In the US it is gay men, African Americans, Latinos/as,
IV drug users, migrants, and the poor who constitute the majority of those infected / affected. A similar social marginalisation pictures apply in most countries, even in African, the epicentre of the epidemic.

It is also crystal clear to me and other HIV experts that French-Canadian flight attendant Gaetan Dugas CANNOT have been 'patient zero' in 1980: it says "All of the city’s early infections would be traced to Dugas" but in that year there were already 52 new people with AIDS in NY alone.
It takes some years after HIV infection for it to progress to AIDS, so there is a missing back story of HIV arriving and then spreading among NY gay population in the years (possibly a whole decade) running up to 1980.

And who knows what was going on in this French-Canadian flight-attendant's home city (Montreal?) and his other ports of call.

Kristina Killgrove said...

Hi, Chris. Thanks for your comment. There's a lot of information in there that I didn't know. I teach classes about ancient diseases, and HIV and AIDS weren't known until this century. But if I ever do use this as a modern example of the construction of knowledge about a disease, I'll definitely check into the sources you've pointed me to!

Anonymous said...

Hi Kristina
I gathered that your classes focus on historical examples, and was hoping to catch the attention especially of people like Michelle who also commented.

I'm not sure what happened to part 2 of my post but the source I would recommend to anyone would be the excellently clear and comprehensive UK HIV information site http://aidsmap.com/resources

Noah said...

i agree with chris, getting the full picture of hiv/aids is important. first, don't refer to aids as a disease, it is a syndrome and only a collection of symptoms and conditions. many feel that the original aids defining conditions, eg. kaposi's sarcoma, need to be revised. aids is seen as a somewhat arbitrary marker of disease state caused by the hiv virus. sorry to be niggling but whenever someone talks about aids as a disease they lose credibility.
second, chris is right. the idea of gaetan dugas being the source patient for the spread of hiv in the usa is full of holes. in fact the idea that he was patient zero was mainly given credence in the Band Played On as plot mechanism for telling a story. there is very little scientific evidence that he was patient zero and the likelihood that he infected the other gay men who were found to have have hiv at the time he was infected is basically zero. we know this because most of the other men were in advanced stages of the disease, meaning that they were not recently infected by gaetan.
the best source of information on this issue is Andrew Moss, one of the original epidemiologists to work on HIV. Check out this letter from Moss published in NYRB in 1988
http://www.nybooks.com/articles/archives/1988/dec/08/aids-without-end-2/

also, this is a great oral history series with an interview with Andrew Moss on the evolution of epidemiological understanding of hiv, including the gaetan hypothesis
http://content.cdlib.org/view?docId=kt7b69n8jn;NAAN=13030&doc.view=frames&chunk.id=d0e8216&toc.depth=1&toc.id=d0e8216&brand=calisphere

last, i hope you persist in creating a curricula on the natural history of this virus because it totally fits neatly in the osteon world view

there is a book that was just published this year about the epidemiological transition of hiv

"The Origins of AIDS" by Jacques Pepin, gives both a detailed account of the probable natural history of the virus as well as fascinating theories posed by Pepin on how the virus spread around the world.
http://www.nytimes.com/2011/10/18/health/18aids.html?_r=1&scp=1&sq=hiv%20aids%20history&st=cse

last, the best critically minded hiv epi today is elizabeth pisani who has a blog Wisdom of Whores, check it out
http://www.wisdomofwhores.com/elizabeth-pisani/

thank you for Osteon, i am inspired by your posts. just last night we were talking about the crucifixion post over merlot at 1am. thanks again,

Kristina Killgrove said...

Thanks, Chris and Noah! As I said, I'm not an epidemiologist by any stretch, so all of this is great information on a syndrome I know little about.

I found the New York Magazine timeline incredibly fascinating but admittedly did not check into the facts behind it. We think of contemporary medicine as so much better than what those crazy ancient people had - but when faced with HIV and AIDS for the first time in the 20th century, doctors, researchers, news sources, etc., all said and did some really stupid things.

It's important to understand that modern medicine doesn't have everything figured out and that new diseases and syndromes are still evolving.

Kristina Killgrove said...

Came across an interesting Radio Lab piece on AIDS. In the blurb, they call it a disease, but they also say that Dugas couldn't have been Patient Zero: http://www.radiolab.org/2011/nov/14/aids/

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