The Coming Plague

by Laurie Garrett

  The infection of another person with AIDS by a person aware of having AIDS shall be punishable by up to eight years in prison.

  13 In fact, according to 1993 Cuban government statistics, more tests were eventually conducted than there were Cubans, meaning some people were repeat-tested. More than 14 million tests were conducted between 1986 and 1993. Some 930 Cubans would test positive during that time, according to Dr. Jorge Pérez. director of Cuba’s Los Cocos AIDS sanitarium in Havana.

  14 Anti-African sentiments were so high that AIDS rumors sparked mini-riots in Beijing and around universities located in other Chinese cities. Deported African students described raids upon their dormitories by citizens’ groups, beatings, and tauntings when they appeared in public places.

  15 For details on the evolution of the Thai sex trade and its influence on the AIDS epidemic, see Asia Watch Women’s Rights Project, A Modern Form of Slavery (New York, Washington, Los Angeles, London: Human Rights Watch, 1994).

  16 C. Decker, “Robertson Tailors His Message to Audiences,” Los Angeles Times. November 23, 1987: Al.

  17 This argument generated an enormous amount of press, and no short list of citations can adequately capture the flavor of this often vociferous debate. For a hint of the atmosphere, see T. Monmaney, P. Wingert, G. Raine, and M. Gosnell, “AIDS: Who Should Be Tested?” Newsweek, May 11, 1987: 64–65; M. Cimons, “Candidates Forced to Deal with AIDS Issue,” Los Angeles Times, November 2, 1987: Al; M. Cimons, “Bowen Against Federal AIDS Legal Protection,” Los Angeles Times, September 22, 1987: A16; R. Shilts, “U.S. Backtracks on AIDS Brochure,” San Francisco Chronicle, August 28, 1987: Al; C. Thomas, “Fight AIDS with a National Health Card,” Editorial, Los Angeles Times, May 5, 1987; M. Cimons, “Conservatives Split as Some Attack Koop,” Los Angeles Times, May 14, 1987: Al; D. Whitman, “A Fall from Grace on the Right,” U.S. News & World Report, May 25, 1987: 27–28; J. Helms, “Only Morality Will Effectively Prevent AIDS from Spreading,” Editorial, New York Times, November 23, 1987; and C. E. Koop, Koop: Memories of America’s Family Doctor (New York: Random House, 1991).

  18 For a flavor of the U.S. immigration debate, see R. M. Wachter, The Fragile Coalition (New York: St. Martin’s Press, 1991).

  19 The distinction between “epidemic” and “endemic” is crucial to all discussion of emerging diseases. Ideally, one hopes to spot an emerging microbe and bring it under control when its impact on Homo sapiens is limited to small outbreaks. Barring that, there may still be hope for effective action against an epidemic, which, by definition, is a new and potentially short-lived phenomenon.

  With microbes like HIV, human papillomavirus, and herpes simplex, it was very difficult to spot emergence at either the outbreak or early epidemic stages because the majority of infected human beings were asymptomatic for months or years. Thus, an epidemic could smolder and spread, unnoticed, for years. Slow-acting viruses offered the greatest challenge to public health advocates, therefore, because it took so long for the public to recognize a threat.

  In the absence of alert public health authorities, such simmering epidemics could easily evolve into endemic diseases in a society before the emergence of the microbe was even noticed. Once a disease was endemic to some segment of a society, it was extremely difficult to defeat.

  The GPA hoped in 1988 to prevent HIV from becoming endemic to most of the societies in the world by shaking governments out of denial and prompting effective action while HIV was still in an outbreak or early epidemic stage of emergence. By 1988 endemicity was already the reality in much of sub-Saharan Africa, North America, and Western Europe. But there was hope for the majority of the world’s populations, residing in Asia, Eastern Europe, Oceania, and Latin America.

  AIDS-RELATED RESTRICTIONS ENACTED INTO LAW AT FEDERAL LEVELS, 1987–89* (Compiled from multiple sources, including WHO; Panos Institute; McGill Centre for Medecine, Ethics and Laws; AIDS Policy Center. Intergovernmental Health Policy Project, George Washington University) * Some of these laws were subsequently revoked. In addition, some countries passed analogues legislation or edicts after 1989).

  In a worst-case scenario HIV would reach endemic status on one or two continents, spread as a pandemic across the rest of the world, and eventually reach a stage of global endemicity, becoming permanently entrenched in every society on earth.

  20 Much has been written about behavioral and societal responses to AIDS, though few serious scientific studies of the matter have been funded. The National Academy of Sciences in the United States identified lack of information about human sexual and drug use behavior and responses to epidemics as the key factors responsible for failure to find ways to stop AIDS. Yet most governments remained loath to sponsor such studies, even thirteen years after the pandemic began, because of the religious, political, and cultural sensitivities involved in queries about sex and drugs.

  See, for example, Centers for Disease Control, “Assessment of Broadcast Media Airings of AIDS-Related Public Service Announcements—United States, 1987–1990,” Morbidity and Mortality Weekly Report 40 (1991): 543–46; Centers for Disease Control, “Attitudes of Parents of High School Students About AIDS, Drug, and Sex Education in Schools—Rome, Italy, 1991,” Morbidity and Mortality Weekly Report 41 (1992): 201–9; Centers for Disease Control, “HIV Prevention in the U.S. Correctional System, 1991,” Morbidity and Mortality Weekly Report 41 (1992): 389–97; Centers for Disease Control, “Street Outreach for STD/HIV Prevention—Colorado Springs, Colorado, 1987–1991,” Morbidity and Mortality Weekly Report 41 (1992): 94–102; A. A. Ehrhardt, “Sex Education for Young People,” presentation to the Ninth International Conference on AIDS, Berlin, June 7–11, 1993; Family Health International, “Strategies for Behavioral Change—Slowing the Spread of AIDS,” Network 12, 1 (1991): 1–28; P. Lamptey, T. Coates, G. Slutkin, et al., “HIV Prevention: Is It Working?” presentation to the Ninth International Conference on AIDS, Berlin, June 7–11, 1993; M. V. Nadel, “AIDS Education: Gaps in Coverage Still Exist,” testimony before the Senate Committee on Governmental Affairs, GAO/ T-HRD-90-26, 1990; National Research Council, AIDS: Sexual Behavior and Intravenous Drug Use, C. F. Turner, H. G. Miller, and L. E. Moses, eds. (Washington, D.C.: National Academy Press, 1989); National Research Council, The Social Impact of AIDS in the United States, A. R. Jonsen and J. Stryker, eds. (Washington, D.C.: National Academy Press, 1993); Office of Technology Assessment, “How Effective Is AIDS Education?” Report to the Congress of the United States, Staff Paper 3, 1988; Panos Dossier (1990), op. cit.; Panos Dossier, AIDS and the Third World (London: Panos Institute and Philadelphia, PA: New Society Publishers, 1989); H. Schietinger, “Good Intentions: A Report on Federal AIDS Prevention Programs” (Washington, D.C.: AIDS Action Council, 1991); J. Sepulveda, H. Fineberg, and J. Mann, AIDS: Prevention Through Education: A World View (New York and Oxford, Eng.: Oxford University Press. 1992); U.S. General Accounting Office, AIDS Education: Public School Programs Require More Student Information and Teacher Training, report to the Chairman, Committee on Governmental Affairs, U.S. Senate, GAO/HRD-90-103, 1990; and U.S. General Accounting Office, AIDS-Prevention Programs: High-Risk Groups Still Prove Hard to Reach, report to the Chairman, Subcommittee on Human Resources and Intergovernmental Relations, Committee on Governmental Operations, House of Representatives, GAO/HRD-91–52, 1991.

  21 British Market Research Bureau Limited, “AIDS Advertising Campaign,” prepared for the Central Office of Information, London, July 1987.

  22 Cuba may be an exception. Through mandatory testing and quarantine, Cuba did succeed in keeping its HIV incidence well below 1 percent of the population for ten years. However, as economic collapse set in following the dissolution of the Soviet state and subsequent cessation of U.S.
S.R. subsidization of Cuban industry and agriculture, prostitution and tourism rose in the island nation. A new wave of AIDS, entirely divorced from that spawned years earlier by veterans of the Angolan civil war, emerged in Cuba during the early 1990s. Most observers, including the Cubans and representatives of the Pan American Health Organization, predicted in 1993 that Cuba’s AIDS incidence would rise as its starving economy was increasingly dependent upon tourism. According to that analysis, the earlier success of a quarantine approach to AIDS depended upon a high level of isolation of the Cuban society as a whole. As Cuba became more open to outsiders, critics said, such restrictive approaches could no longer be expected to succeed.

  See R. Goldstein, “AIDS Arrest: The Cuban Solution,” Village Voice, February 14, 1989: 18; N. Caistor, “Treatment for Life,” New Scientist, February 18, 1989: 65; A. M. Gordon and R. Paya, “Controlling AIDS in Cuba,” New England Journal of Medicine 321 (1989): 829; R. Bayer, “Controlling AIDS in Cuba: The Logic of Quarantine,” New England Journal of Medicine 320 (1989): 1022–24; N. Scheper-Hughes, “AIDS, Public Health, and Human Rights in Cuba,” Lancet 342 (1993): 965–67; and J. Glesecke, “AIDS and the Public Health,” Lancet 342 (1993): 942.

  23 World Summit of Ministers of Health on Programmes for AIDS Prevention, “London Declaration on AIDS Prevention,” January 28, 1988, in World Health Organization,AIDS Prevention and Control (Oxford, Eng.: Pergamon Press, 1988).

  24 See F. Newman and D. Weissbrodt, Selected International Human Rights Instruments (Cincinnati, OH: Anderson Publishing Co., 1990); K. Tomasevski, S. Gruskin, Z. Lazzarini, and A. Hendriks, “AIDS and Human Rights,” in Mann, Tarantola, and Netter, eds. (1992), op. cit.; P. Siegert, AIDS and Human Rights: A UK Perspective, British Medical Foundation for AIDS, London; and “Declaration on Respect for Human Rights and Dignity in Addressing the AIDS Pandemic,” Global Expert Meeting, The Hague, Netherlands, May 21–24, 1991.

  25 See L. O. Gostin, “The Americans with Disabilities Act and the U.S. Health Care System,” Health Affairs 11, 3 (1992): 248–57; L. O. Gostin, “Public Health Powers: The Imminence of Radical Change,” The Milbank Quarterly 69 (1991): 268–90; L. O. Gostin, “A Decade of a Maturing Epidemic: An Assessment and Directions for Future Public Policy,” American Journal of Law and Medicine 15, 1 and 2 (1990); L. O. Gostin, “The AIDS Litigation Project: A National Review of Court and Human Rights Commission Decisions. Part I: The Social Impact of AIDS,” Journal of the American Medical Association 263 (1990): 1961–70; and L. O. Gostin, “The AIDS Litigation Project: A National Review of Court and Human Rights Commission Decisions. Part II: Discrimination,” Journal of the American Medical Association 263 (1990): 2086–93.

  26 African AIDS Cases Officially Reported to the World Health Organization

  27 “The Politics of AIDS,” New African, February 1990: 28.

  28

  29 R. Shilts, “Economists Predict Hard Times for Africa’s ‘AIDS Belt,’” San Francisco Chronicle, March 10, 1988: A4.

  30 About $1.00 for a first-round ELISA blood test and $30 to $50 for Western Blot confirmatory assays, based on technology available in 1988, plus the purchase of an ELISA screening machine: $15,000.

  31 Estimated in 1988 to cost $5.00 for 100 condoms if bulk-purchased at discount, or up to twenty times that amount if purchased individually at retail cost.

  32 J. Tinker, “AIDS in Developing Countries,” Issues in Science and Technology IV (Winter 1988): 1–7.

  33 There were a variety of estimates for U.S. AIDS treatment costs, some topping $200,000. In general, annual costs decreased over the years as physicians gained skills in handling AIDS cases. But lifetime cumulative AIDS costs increased because patients lived longer and accrued greater expenses. See G. J. Alpauch, “AIDS-Related Claim Survey Results,” Best’s Insurance Management Reports, November 18, 1991: 1–3; L. S. Rosenblum, J. W. Buehler, M. Morgan, and M. Moien, “Increasing Impact of HIV Infection on Hospitalizations in the United States, 1983–1988.” Journal of Acquired Immune Deficiency Syndromes 5 (1992): 497–504; General Accounting Office, “AIDS Forecasting: Undercount of Cases and Lack of Key Data Weaken Existing Estimates,” Report to U.S. Congress, Washington, D.C., 1989; “AIDS: Met Life’s Experience, 1986–89,” Met Life’s Statistical Bulletin, October-December 1990: 2–9; A. A. Scitovsky, “The Economic Impact of AIDS in the United States,” Health Affairs, Fall 1988: 1–14; F. J. Hellinger, “Forecasting the Medical Care Costs of the HIV Epidemic: 1991–1994,” Inquiry 28 (1991): 213–225; and L. T. Bilheimer, “Modeling the Impact of the AIDS/HIV Epidemic on State Medical Programs,” presentation to the Conference on New Perspectives on HIV-Related Illness: Program in Health Services Research, U.S. Public Health Service, Rockville, MD, 1989.

  34 M. Over, S. Bertozzi, J. Chin, et al., “The Direct and Indirect Cost of HIV Infection in Developing Countries: The Cases of Zaire and Tanzania,” presentation to the Fourth International Conference on AIDS, Stockholm. June 12–16, 1988.

  35 Using similar calculations, the average 1988 AIDS patient cost the United States three years of per capita GNP, and as the American epidemic increasingly shifted into communities of extreme poverty that cold value fell further. Using these admittedly crude early attempts at pricing out the AIDS epidemic, 250,000 U.S. cases of AIDS might cost the economy 750,000 years of per capita GNP. But 250,000 Zairian cases would tax that economy to the tune of 4,750,000 years of per capita GNP. See also M. Over, S. Bertozzi, and J. Chin, “A Proposed Approach to Making Preliminary Estimates of the Cost of HIV Infection in a Developing Country,” presentation to the Third International Conference on AIDS and Associated Cancers in Africa, Arusha, Tanzania, September 16, 1988.

  36 S. K. Lwangwa and J. Chin. “Projections of Non-Paediatric HIV Infection and AIDS in Pattern II Areas,” presentation to the Fifth International Conference on AIDS, Montreal, June 4–9, 1989.

  37 For a sense of the mood in the Global Programme on AIDS, see S. Kingman, “AIDS Brings Health into Focus,” New Scientist, May 20, 1989: 37–42; J. M. Mann, “Global AIDS: Into the 1990s,” presentation to the Fifth International Conference on AIDS, Montreal, June 4–9, 1989; and World Health Organization, “Global Programme on AIDS,” prepared for Delegates at the Fifth International Conference on AIDS, Montreal, June 4–9, 1989.

  38 World Health Organization, “The Global AIDS Situation,” In Point of Fact 68, 1990; and World Health Organization, “WHO Revises Global Estimates of HIV Infection,” WHO Press, WHO/ 38, July 31, 1990.

  39 M. Over and P. Piot, “HIV Infection and Other Sexually Transmitted Diseases,” Chapter 10 in D. T. Jamison and W. H. Mosley, eds., World Health Report (Washington, D.C.: World Bank, 1990).

  40 H. M. Ntaba, “Access to Health Care—AIDS in the Developing World,” presentation to the Sixth International Conference on AIDS, San Francisco, June 20–24, 1990.

  41 E. M. Kiereini, “Women and Children in Africa: AIDS Impact,” presentation to the Sixth International Conference on AIDS, San Francisco, June 20–24, 1990.

  42 The role of women in African societies and its relationship to AIDS proved to be the greatest stumbling block to efforts to control the expanding epidemic. Women could not in most African societies insist that their partners use condoms. To do so could mean death, for wives were often of such low status compared with their husbands that they had little right to question any of his sexual practices. Even after a man had been diagnosed as having AIDS, in many African countries he might legally insist that his wife yield to unprotected intercourse. Such rights have been challenged of late in the courts of Zambia, Zimbabwe, Kenya, Côte d’Ivoire, Nigeria, an
d other countries on the continent.

  Thankfully, much has been written over the last five years about this subject, and the once taboo issue of women’s rights is becoming the subject of discussion for Africa.

  For further insight, see L. Garrett, “AIDS in Africa,” Newsday, December 26 and 27, 1988: Al; L. Garrett, “AIDS: What Women Don’t Know,” Elle, December 1992: 86–96; Global Programme on AIDS, “International Conference on the Implications of AIDS for Mothers and Children: Technical Statements and Selected Presentations,” Paris, November 27–30, 1989; B. Grundfest-Schoepf, W. Engundu, R. waNkera, et al., “Research on Women with AIDS,” presentation to the First International Conference on AIDS Education and Information, Ixtapa, Mexico, October 16, 1989; C. G. Moreno and L. C. Rodrigues, “Safer Sex and Women in Africa,” Lancet 340 (1992): 57–58; E. Ojulu, “Uganda Prostitutes Are Now Wiser,” New African, September 1988: 34; Panos Dossier, Triple Jeopardy—Women and AIDS (Washington, D.C.: Panos Institute, 1990); J. Perlez, “Toll of AIDS on Uganda’s Women Puts Their Roles and Rights in Question,” New York Times, October 26, 1990: A14; A. Petras-Barvazian and M. Merson, “Women and AIDS: A Challenge for Humanity,” World Health, November-December 1990: 1–32; and “Women and Prevention Strategies,” AIDS Newsletter, 1992: Item 16, Item 515.