The Coming Plague

by Laurie Garrett

  96 As of March 1990 the Eastern bloc had officially reported cumulative AIDS cases and other related findings as follows:

  GDR (East Germany) 277 AIDS cases. Government reports a rise in heroin use since the fall of the Wall.

  Czechoslovakia 19 AIDS cases

  Hungary 32 AIDS cases. Homosexual groups given government approval January 1, 1990, to begin AIDS education campaigns.

  Albania 0 AIDS

  Soviet Union 18 AIDS cases. 30 million people allegedly HIV-tested since 1987, of whom 722 were found to be positive.

  Romania 74 AIDS cases (50 babies). In addition, 799 of 2,850 children tested are HIV-positive.

  Poland 348 AIDS cases. Government reports sharp increase in heroin in the country since the fall of the Wall.

  Bulgaria 10 AIDS cases. Total of 2.75 million tested, 23 found HIV-positive.

  97 L. Garrett, “AIDS in Eastern Europe: Tragedies Out in the Open,” Newsday, March 6, 1990: 1.

  98 Trud investigators estimated that 6 billion injection/withdrawal procedures were performed each year, but only 45 million sterile syringes were manufactured. Thus, each syringe was reused an average of 133 times.

  99 Vadim Pokrovsky headed up the Specialized Research Laboratory on AIDS, located in Moscow. His father, Valentin, was head of the National Virology Institute in Moscow, President of the Soviet Academy of Sciences, and an early pioneer in AIDS research in that country. Their names were often confused in Western press accounts.

  100 Based on data compiled by the Russian State Committee on Sanitary and Epidemiologic Surveillance, the Russian Republic Information and Analytic Center, and Science magazine [“Resurging Infectious Diseases in Russia,” Science 261 (1993): 415], disease rates soared between May 1992 and May 1993:

  101 A. V. Yablokov, “The Need for a New Approach to Definition of Priority Health Problems of Populations of the Russian Federation,” address to the Security Council, March 17, 1993.

  102 E. Taylor, C. P. Besse, and T. Healing, “Tuberculosis in Siberia,” Lancet 343 (1994): 968.

  103 Centers for Disease Control, “Diphtheria Outbreak—Russian Federation, 1990–1993,” Morbidity and Mortality Weekly Report 42 (1993): 840–47; World Health Organization, “Diphtheria in the Former Soviet Union: The Epidemic Continues,” Press Release WHO/70 (September 10, 1993); C. Bohlen, “Diphtheria Epidemic Sweeps Russia,” New York Times, January 29, 1993: A12; and S. Erlanger, “Diphtheria Afflicting Russia, Kills 100 This Year,” New York Times, August 22, 1993: A8.

  104 J. Lumio, M. Jahkola, R. Vuento, et al., “Diphtheria After Visit to Russia,” Lancet 342 (1993): 53–54; and A. Dezoysa, A. Efstantious, R. C. George, et al., “Diphtheria and Travel,” Lancet 342 (1993): 446.

  105 For details on the Romanian cases, see C. Bohlen, “Romania’s AIDS Babies: A Legacy of Neglect,” New York Times, February 8, 1990: Al; A. Purvis and M. Hornblower, “Rumania’s Other Tragedy,” Time, February 19, 1990: 74; 1. V. Patrascu, St. N. Constantinescu, and A. Dublanchet, “HIV-1 Infection in Romanian Children,” Lancet I (1990): 672; World Health Organization, “World Health Organization Announces Emergency AIDS Action Plan for Romania,” Press Release WHO/10/ 16 February 1990; S. Dickman, “AIDS in Children Adds to Romania’s Troubles,” Nature 343 (1990): 579; L. Garrett, “The Baby Experiments,” Newsday, October 28, 1990: 7; and J. Pope, “Tulane Probing Doctor’s Role in AIDS Test,” Times-Picayune (New Orleans), October 30, 1990: Al, A6.

  106 N. Beldescu, presentation to the Sixth International Conference on AIDS, San Francisco, June 19–23, 1990. (Not formally on the conference agenda.)

  107 B. S. Hersh, J. M. Oxtoby, F. Popovici, et al., “Acquired Immunodeficiency Syndrome in Romania,” Lancet 338 (1991): 645–49.

  108 J. Knowles, “The Responsibility of the Individual,” in Doing Better and Feeling Worse: Health in the United States, Special Issue of Daedalus, 1977.

  109 J. B. McKinlay and S. M. McKinlay, “The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century,” Milbank Memorial Fund Quarterly, Summer 1977; D. Fife and C. Mode, “AIDS Incidence and Income,” Journal of Acquired lmmune Deficiency Syndromes 5 (1992): 1105–10; New York State Department of Health, “AIDS in New York State—1992,” Public Affairs Group, Albany, NY, 1993; and Committee on AIDS Research and the Behavioral, Social, and Statistical Sciences. National Research Council, “The AIDS Epidemic in the Second Decade,” Chapter 1 in H. G. Miller, C. F. Turner, and L. E. Moses, eds., AIDS: The Second Decade (Washington, D.C.: National Academy Press, 1990).

  110 A private survey forecast 80,000 children under age eighteen would be AIDS orphans by the year 2000. See D. Michaels and C. Levine, “Estimates of the Number of Motherless Youth Orphaned by AIDS in the United States,” Journal of the American Medical Association 268 (1992): 3456–61.

  The researchers made high and low estimates of the New York City orphan problem as follows:

  Cumulative Number

  Year Low Range High Range

  1991 15,200 22,000

  1995 39.200 56,700

  2000 72,000 125,000

  111 According to Harvard School of Public Health economist Kathy Schwartz, U.S. medical insurance/noninsurance broke down in 1990 as follows:

  Completely Uninsured Population: 37 million people

  (29%) 10.7 million—below povertya incomes

  (20%) 7.4 million—incomes 100–199% above poverty

  (18%) 6.6 million—incomes 200–300% above poverty

  (22%) 8.1 million—incomes 300% above poverty

  26% were children under 17

  25% were 18–24 years of age

  10% were 45–54 years of age

  7% were 55–64 years of age

  60% of adults were employed

  Underinsured Population: 40 million people

  Chronically Uninsured Population: 3–5 million people

  Reinhardt estimated that in 1987 Americans spent $500 billion on health care, or 11.1 percent of the GNP.

  According to the U.S. government’s Health Care Financing Administration (HCFA), health care spending as a percentage of U.S. GNP rose steadily between 1975 and 1987; from 8.3 percent of GNP in 1975 to 11.1 percent in 1987.

  Between 1980 and 1987 actual health care expenditures, in all forms, leapt from about $641.9 billion to $1,306,600,000,000, or $1.3 trillion. That was a 181.5 percent increase in seven years, making health care the most rapidly inflating sector of the U.S. economy, and U.S. health care the most inflationary of any industrialized nation.

  See U. E. Reinhardt, “The United States: Breakthroughs and Waste,” Journal of Health Politics, Policy and Law 17 (1992): 637–66.

  112 The American Hospital Association estimated that 14 percent of American hospitals—all of them large teaching facilities and public institutions—handled 80 percent of all inpatients in the United States in 1988.

  113 B. Lambert, “One in 61 Babies in New York City Has AIDS Antibodies, Study Says,” New York Times, January 13, 1988: Al; and L. F. Novick, ed., “New York State Seroprevalence Project,” American Journal of Public Health (Supplement) 81 (1991): 1–61.

  114 P. S. Rosenberg, R. J. Biggar, and J. J. Goedert, “Declining Age at HIV Infection in the United States,” New England Journal of Health 330 (1993): 789; and T. A. Green, J. M. Karom, and O. C. Nwanyanwu, “Changes in AIDS Incidence Trends in the United States,” Journal of Acquired lmmune Deficiency Syndromes 5 (1992): 547–55.

  115 R. Gorter, R. Meakin, A. Keffelew, et al., “Homelessness and HIV Infection: A Population Based Study,” presentation to the Seventh International Conference on AIDS, Florence, June 16–21, 1991
.

  116 Again, absent the impact of AIDS, racial disparities in health were glaring throughout the United States. Consider the following (1988) data:

  • White babies were 70 percent more likely than black babies to survive to age four.

  • Average life expectancies (genders combined) for whites were 76 years, blacks 70.3 years.

  • Black men were 50 percent more likely to die of heart attacks than their white counterparts.

  • Black children were three times more likely than whites to die of pneumonia or meningitis due to an assortment of microbial infections.

  • Thirty-three percent of blacks lived below the official poverty line, compared to 12 percent of whites.

  • Infant mortality was 9.2 per 1,000 live births for whites, but 18 per 1,000 for blacks.

  • Fifty percent of black women received a first breast cancer diagnosis after the malignancy had become untreatable, compared with 8 percent of white women.

  • Between a third to a half of all black men in the United States (rates vary geographically) were unemployed, a rate at least 10 percent higher than the general rate during the Great Depression.

  • More black men died as a result of homicide in the United States in 1977 than did fighting for over ten years in the Vietnam War.

  See J. Taylor Gibbs, ed., Young, Black and Male in America: An Endangered Species (Berkeley, CA: Auburn House, 1988).

  117 The 1990 U.S. Census revealed that half of the nation’s five million divorced single mothers were not receiving court-ordered child support payments because the fathers were delinquent: the majority of these women and children ended up among the nation’s officially counted impoverished citizens.

  See 1993 annual reports of Second Harvest, the Urban Institute, and Food Research and Action Center. See also 1990 U.S. Census Report; R. Pear, “Poverty in U.S. Grew Faster Than Population Last Year,” New York Times, October 5, 1993: A20; D. Wallace, “Poverty and Disease in the USA,” Lancet 343 (1993): 238–39; J. Freedman, From Cradle to Grave: The Human Face of Poverty in America (New York: Atheneum, 1993); and E. L. Bassuk, “Homeless Families,” Scientific American, December 1991: 66–74.

  118 Institute of Medicine, Homelessness, Health, and Human Needs (Washington, D.C.: National Academy Press, 1988); Committee on Public Health, “Housing and Health: Interrelationship and Community Impact,” Bulletin of the New York Academy of Medicine 66 (1990): 379–591; and S. L. Neibacher, ed., “Homeless People and Health Care: An Unrelenting Challenge,” United Hospital Fund, Paper Series 14 (December 1990), New York.

  119 R. Rosenheck, L. Frisman, and A. M. Chung, “The Proportion of Veterans Among Homeless Men,” American Journal of Public Health 84 (1994): 466–69; and Institute of Medicine (1988), op. cit.

  120 K. Hopper, “New Urban Niche,” Bulletin of the New York Academy of Medicine 66 (1990): 435–50.

  121 Committee for the Study of the Future of Public Health, Institute of Medicine, The Future of Public Health (Washington, D.C.: National Academy Press, 1988).

  122 Centers for Disease Control, “Measles—New York,” Morbidity and Mortality Weekly Report 29 (1980): 452–53; and Centers for Disease Control, “Measles—United States, First 39 Weeks of 1980,” Morbidity and Mortality Weekly Report 29 (1980): 501–2.

  123 Averaged across all ages, encephalitis, which can lead to permanent brain damage and/or death, occurs in one out of every 2,000 measles cases in industrialized nations. Death due to either respiratory failure or neurological damage occurs in one out of every 3,000 measles cases. See Centers for Disease Control, “Measles Prevention,” Morbidity and Mortality Weekly Report 36 (1987): 409–25.

  124 T. L. Gustafson, A. W. Lievens, P. A. Brunell, et al., “Measles Outbreak in a Fully Immunized Secondary-School Population,” New England Journal of Medicine 316 (1987): 771–74.

  125 M. B. Edmonson, D. G. Addiss, J. T. McPherson, et al., “Mild Measles and Secondary Vaccine Failure During a Sustained Outbreak in a Highly Vaccinated Population,” Journal of the American Medical Association 263 (1990): 2467–71.

  126 S. H. Lee, D. P. Ewert, P. D. Frederick, and L. Mascola, “Resurgence of Congenital Rubella Syndrome in the 1990s,” Journal of the American Medical Association 267 (1992): 2616–20; D. E. Shalala, “Giving Pediatric Immunizations the Priority They Deserve,” Journal of the American Medical Association 269 (1993): 1844–45; and Centers for Disease Control, “Resurgence of Pertussis—United States, 1993,” Morbidity and Mortality Weekly Report 42 (1993): 952–65.

  127 V. S. Mitchell, N. M. Philipose, J. P. Sanford, The Children’s Vaccine Initiative: Achieving the Vision (Washington, D.C.: Institute of Medicine, National Academy Press, 1993); G. Peter, “On the Measles Epidemic,” testimony before the U.S. House of Representatives Subcommittee on Health and the Environment of the Committee on Energy and Commerce, March 11, 1991; and National Vaccine Advisory Committee, “The Measles Epidemic: The Problems, Barriers and Recommendations,” Executive Report, January 8, 1991, Washington, D.C. [a summary can be found in the Journal of the American Medical Association 266 (1991): 1547–52].

  128 A great deal has been written elsewhere about this alarming trend, which worsened markedly after 1985. The lack of primary health care in impoverished urban areas, overutilization of tertiary facilities, and greater cost to society have been well documented elsewhere.

  See, for example, D. E. Rogers and E. Ginzberg, Medical Care and the Health of the Poor (Boulder, CO: Westview Press, 1993); L. K. Abraham, Mama Might Be Better Off Dead: The Failure of Health Care in Urban America (Chicago: University of Chicago Press, 1993); A. Carper, “Ailing Grades: Index Shows Need for More Primary Care,” New York Newsday, October 10, 1993: 7, 58; J. Hadley, E. P. Steinberg, and J. Feder, “Comparison of Uninsured and Privately Insured Hospital Patients,” Journal of the American Medical Association 265 (1991): 374–79; V. R. Fuchs and D. M. Reklis, “America’s Children: Economic Perspectives and Policy Options,” Science 255 (1992): 41–46; J. Mangaliman and K. Freifeld, “City Hell for Kids,” New York Newsday, September 30, 1993: 4; and C. Woodard, “Report: Many Kids Not Immunized,” New York Newsday, September 1, 1993: 12.

  129 S. F. Davis, P. M. Strebel, W. L. Atkinson, et al., “Reporting Efficiency During a Measles Outbreak in New York City, 1991,” American Journal of Public Health 83 (1993): 1011–15; and S. Friedman, “Measles in New York City,” Journal of the American Medical Association 266 (1991): 1220.

  130 According to Bloom, in 1992 the following were the rates of successful completion of childhood vaccination recommended by age two in selected areas of the United States:

  City/State % of Children Age 2 Who Have Fulfilled WHO Vaccination Recommendations (excluding BCG)

  Houston 10

  Bronx, NY 38

  Miami 27

  New Hampshire 79

  Vermont 68

  Tennessee 70

  Massachusetts 57

  California 48

  New York State 56

  Arkansas 42

  Utah 36

  Missouri 44

  New York City 38

  Chicago 27

  See also J. Cohen, “Childhood Vaccines: The R and D Factor,” Science 259 (1993): 1528–29; and “Vaccine Demand and Supply,” in Mitchell, Philipose, and Sanford (1993), op. cit.

  131 Centers for Disease Control, “Vaccination Coverage of 2-Year-Old Children—United States, 1991–92,” Morbidity and Mortality Weekly Report 42 (1994): 985–88; E. R. Zell, V. Dietz, J. Stevenson, et al., “Low Vaccination Levels of U.S. Preschool and School-Age Children,” Journal of the American Medical Association 271 (1994): 833–39; and Centers for Dise
ase Control, “Reported Vaccine-Preventable Diseases—United States, 1993, and the Childhood Immunization Initiative,” Morbidity and Mortality Weekly Report 43 (1994): 57–61.

  132 See R. Dubos and J. Dubos, The White Plague: Tuberculosis, Man, and Society (New Brunswick, NJ: Rutgers University Press, 2nd paperback edition, 1992); and F. Ryan, The Forgotten Plague: How the Battle Against Tuberculosis Was Won—and Lost (Boston: Little, Brown, 1992).