email Dr Kerns
The Thesis position urges that "In
the face of so much growing personal tragedy associated with HIV
infection, and in the face of such a rapidly expanding global
pandemic, waiting any longer to initiate phase I and II trials
for HIV vaccines would simply be wrong." In order to have
any notion of the full force of this claim, we will need to have
some elementary understanding of the present scope and predicted
future course of the HIV/AIDS pandemic.
It is difficult, however, to convey any full sense of the enormity
of a pandemic.
Because it is so difficult, I often ask students in my courses
on Medical Ethics and the AIDS pandemic to read Daniel Defoe's
A Journal of the Plague Year. In this novel the impact
of the Black Death in London that year (1665) comes across most
clearly in the day to day details. We see infected mothers and
their children shut up inside their houses, with guards stationed
in front to insure that they do not come out. We see carts full
of bodies being wheeled off in the early morning hours to stinking
mass graves just outside town. We see the weekly mortality sheets
recording the numbers of dead for the previous week. We see people
packing their goods into a cart and leaving town to live elsewhere
if they can afford to do so. We see people losing faith in their
God, and then we see others believing even more strongly and praying
even more fervently than they prayed to their God before. We see
individuals responding daily to the threat of coming down with
a mortal sickness that they've seen their friends and family members
die of only days ago. We see people who are healthy today coming
down with the sickness and dying before tomorrow's supper. These
daily details bring home to readers the impact of living in the
midst of an epidemic of lethal infectious disease.
Similarly, daily details of what it is like to live in the midst
of the AIDS pandemic can be seen in the daily events recorded
in biographical and autobiographical writings of people like Robert
O'Boyle, Paul Monette, Barbara Peabody, Anne Richardson, Dietmar
Bolle, and countless others who have effectively chronicled their
own and others' personal experiences with AIDS. It is these personal
accounts of living with a new truth (or perhaps with an old truth
never before fully understood) that bring the reality of the epidemic
alive for us. These authors do an enormous service for those who
do not live directly in the front lines of the pandemic.
Yet at some point the impact of the pandemic must be somehow reduced
to numbers, laid out in the stark black suit of quantity, if we
are ever to adequately characterize its scope.
The Tenth International Conference on AIDS, held in Yokohama in
August of 1994, tried to do just that. During that conference,
the following summary of the pandemic's extent and demography
was distributed by Dr Jonathan Mann (Director of the Global AIDS
Policy Coalition at Harvard, and first Director of the World Health
Organization's Global Programme on AIDS) and Daniel Tarantola,
also of Harvard's GAPC. The numbers are stark and the passage
is lengthy, but please read these data carefully. The statistics
tell a powerful story.
As of 1 January 1994, the Global AIDS Policy Coalition estimated that 22.2 million people worldwide had been infected with HIV since the beginning of the pandemic. Of these, 20 million were adults (11.3 million men and 8.7 million women) and 2.2 million were children. The largest numbers of HIV-infected people were in sub-Saharan Africa (15.5 million; 70 percent of global total) and Southeast Asia (3 million; 14 percent). The number of HIV-infected people in Southeast Asia now exceeds the total of infected people in the entire industrialized world. Thus, the large majority of HIV infections (20.2 million; 91 percent) have occurred in the developing world. Worldwide, an estimated 16.2 million people were living with HIV or AIDS on 1 January 1994.
The global total of cumulative HIV infections in adults has more than doubled in four years, from nearly 10 million in 1990 to 20 million in 1994....
During 1993, over 3.7 million new infections occurred worldwide in adults and children - over 10,000 a day. Sub-Saharan Africa contributed 1.8 million infections (49 percent) to the global total and Southeast Asia had 1.5 million (40 percent). During 1993, the industrialized world accounted for over 200,000 new infections (6 percent); clearly the burden of new HIV infections is increasingly borne by developing countries (over 3.5 million, or 94 percent). Globally, during 1993, 1.4 million women were newly infected, representing 40 percent of all new adult infections that year....
Globally, during 1993, over 350,000 children were born with HIV infection....
The epidemic has not been stopped in any country; the cumulative number of HIV infections continues to rise relentlessly....
The gap between the expanding pandemic and the response is growing rapidly and dangerously, [and] efforts in prevention and care are becoming fragmented....
[T]he current global AIDS strategy...is not sufficient to meet the challenges of the pandemic....
In Thailand, for example, as in
some other developing countries, the epidemic is almost out of
control. The infection rate, says Dr. Prayura Kunasol, head of
Thailand's Department of Communicable Disease Control, "has
hit 20 percent among young military recruits - and 8 percent amount
pregnant women - in the country's northern Chang Mai province.
AIDS patients now occupy half of Chang Mai's hospital beds".
Although HIV began to spread widely in Thailand only as recently
as 1987, already infection levels are approaching 23 percent of
the reproductive age population. The three factors that are largely
responsible for this discouraging situation in Thailand are: a)
the rapid growth of HIV infection nationwide, b) the fact that
infection is not limited to identifiable "risk groups"
(for example, gay men or injection drug users) but is spread throughout
the "general population," and c) the presence of a large
infected but still symptom-free (hence unidentifiable) population
of HIV carriers, most of whom do not realize that they are infected,
and who will then probably be spreading the virus to their sex
partners. HIV positive women who become pregnant also risk spreading
the infection to their fetuses. These three features are not unique
to Thailand, but actually characterize many Asian countries.
In India, for example, "studies have documented infection
rates of 50-75 percent among IV-drug users in some provinces",
and in Bombay "the rate [of HIV infection] among prospective
blood donors shot from less than 1 percent in 1992 to 5 percent
last year". This figure has tremendous consequences for protecting
the quality of the national blood supply, especially since in
India blood-testing facilities outside of major cities are rare.
India simply cannot afford to test any more than a small fraction
of blood donations at present.
Nor are India and Thailand unique. Drug use, commercial sex and
general ignorance about the risks of HIV transmission unfortunately
are commonplace in many countries, both industrial and developing.
Economic difficulties exacerbate the problems. Cambodia, for example,
does indeed have a national AIDS prevention program, but it has
not been implemented because of lack of funding.
These examples are from Asia, but the situation in South America
is not much better, and the situation in Africa is very much worse.
No statistic tells it as clearly as this one: "Less than
ten per cent of the world's population but more than 60 per cent
of the world's HIV-infected people are African."
Thus, if we had to sum up the state of the global epidemic so
far, we would have to say that it is getting worse by the day.
In the US it is estimated that there is one new HIV infection
every 9 or 10 minutes. That statistic, tragic though it is, is
not as dramatic as the statistics for the whole globe. When I
began teaching courses on Medical Ethics and AIDS in 1987, I could
accurately tell students that, according to the most current data,
there was a new HIV infection somewhere in the world every 30
seconds. A few years later I could tell students that there was
one new infection every 20 seconds. When I taught the course in
early 1994 I could tell them there was a new infection every 10
seconds. According to the figures above which were released at
the Yokohama conference, there is now a new HIV infection somewhere
in the world every 8.5 seconds.
Nor do these numbers take into account the dramatic resurgence
of "the white plague," tuberculosis, which has been
recrudescing in direct proportion to the global increase in HIV
disease. HIV disease, or in fact any immunodeficiency condition
regardless of its cause, is a direct correlate to the increase
in active TB cases. In fact, of all the opportunistic infections
associated with AIDS, tuberculosis is the most common, worldwide,
and is the only OI that puts non-HIV-infected persons at any significant
risk.
What is also true, though not so commonly known, is that the presence
of active tuberculosis infection(indeed, the presence of any active
mycobacterium infection) in an individual HIV+ person appears
to speed the progress of HIV infection in that individual so that
they proceed to active AIDS much more rapidly. It can be said,
therefore, that HIV is a catalyst for the increase of TB in a
community, and that TB is a catalyst for the increase of AIDS
both in individuals and in communities.
This is indeed a bleak picture of an epidemic that C. Everett Koop, former US Surgeon General, has called "the number one health problem on this planet".
Epidemiological statistics are not, of course, the only measure of an epidemic. AIDS, we have discovered, is at least as much a social, political, and economic problem as it is a medical problem. In fact every major epidemic is a social and political problem as much as it is a medical problem. Writing in 1976, five years before the first case of AIDS had been noticed or identified, historian William McNeill tried to describe the effects of epidemics in past ages:
The disruptive effect of...epidemic[s] is likely to be greater than the mere loss of life, severe as that may be. Often survivors are demoralized, and lose all faith in inherited custom and belief which had not prepared them for such a disaster.... Population losses within the twenty to forty age bracket are obviously far more damaging to society at large than comparably numerous destruction of either the very young or the very old. Indeed, any community that loses a substantial percentage of its young adults in a single epidemic finds it hard to maintain itself materially and spiritually. When an initial exposure to one civilized infection is swiftly followed by similarly destructive exposure to others, the structural cohesion of the community is almost certain to collapse.
His concern is shared by others.
Susan Sontag, in her literary study, AIDS and Its Metaphors,
quotes a German AIDS specialist, Dr Eike Brigitte Helm, who says
that "in a number of parts of the world AIDS will drastically
change the population structure. Particularly in Africa and Latin
America. A society that is not able, somehow or other, to prevent
the spread of AIDS has very poor prospects for the future."
Then Jonathan Mann tells us that in fact not one society so far
has succeeded in preventing the spread of AIDS. "No community
or country in the world already affected by AIDS can claim that
HIV spread has stopped."
We have here, it seems, the makings of a syllogism. It looks something
like this:
Premise:
Any society that cannot prevent the spread of AIDS has very poor
prospects for the future.
Premise: Every society already affected by AIDS has failed
to prevent the spread of AIDS.
The conclusion to this little
syllogism would seem to be momentous:
Every society already affected by AIDS has poor prospects for
the future.
A conclusion of this sort may perhaps
be slightly hyperbolic for some societies, but is probably an
accurate conclusion for others.
In underdeveloped communities, for example, whether in developing
nations or developed nations, AIDS is expected to have widespread
devastating consequences. Social structures and economic support
systems in these communities have less "give" in them
because there are fewer redundant systems to use for backup when
a main system fails. Furthermore, because AIDS strikes at the
young adult population, that is, at those persons in a society
who are producing a large percent of the goods and services for
the community, and who are also the parents and breadwinners in
families, the economic consequences to these societies, which
are already severe, are only expected to get worse.
There may be labor shortages, for example, and these shortages
could slow down or even reverse recent development gains. Furthermore,
"economies may be further damaged by declines in foreign
investment or by a drying up of tourism. In many Asian societies,
the elderly are dependent on their working sons and daughters
for support. When their children die, not only will the elderly
often find themselves unsupported, but they may have to take responsibility
for their orphaned grandchildren." Thus, the direct impact
on families and on the raising of children (who are the community's
future) can be expected to be significant.
Globally, in economic terms, the costs are surprisingly large.
The United Nations Human Development Report 1994 features
a prominent sidebar titled "HIV and AIDS - a global epidemic,"
in which is summarized some of the information you've just read.
Then they present some calculations of economic impact:
Costs of the epidemic, of course, include a wide variety of factors.
There are direct medical and hospitalization costs, research costs,
prevention costs, public health program costs, education costs,
and many others, and there are also the indirect costs of years
of potential life lost (YPLL), of lost productivity, and of the
further consequent economic fallout from that lost productivity.
The United Nations Development Programme attempted to quantify
these costs. They calculated some conservative estimates of what
these costs have totaled to date, and what they might be expected
to rise to in the future. Here are their figures:
The cumulative direct and indirect costs of HIV and AIDS in the 1980s have been conservatively estimated at $240 billion. The social and psychological costs of the epidemic for individuals, families, communities and nations are also huge - but inestimable....
The global cost - direct and indirect - of HIV and AIDS by 2000 could be as high as $500 billion a year - equivalent to more than 2% of global GDP.
This conservative estimate of the
annual costs of this pandemic by the year 2000, only four years
away, is staggering and can be expected to have serious economic
implications for the whole globe. It certainly lends credence
to the assertion that something must be done to stem the problem.
The epidemic does not look like it will go away on its own.
The United Nations has once again recognized the world wide impact
of this pandemic and has announced a major reorganization of its
global efforts at controlling the disease. In place of the WHO's
Global Programme on AIDS (which will soon no longer exist), there
will be an overall, high-level coordinating agency (to be called
the "UN Programme on HIV/AIDS," headed by Belgian scientist,
Dr Peter Piot, that will have the function of bringing together
and focusing the efforts of all the various United Nations agencies
that deal with AIDS. UN agencies that currently deal with AIDS
include the World Health Organization, the United Nations Development
Program (UNDP), the United Nations Population Fund (UNFPA) UNESCO,
UNICEF, and the World Bank. (The UN is to be applauded for its
long recognition that AIDS, in addition to its dimension as a
medical problem, is also a social, economic, educational, research
and political problem as well.) The announcement of this major
organizational change in the WHO's approach to the AIDS pandemic
marks the first time in the 50-year history of the UN that any disease or health crisis has been elevated to such a level. This is occurring because the international community has never before faced such an intractable, rapidly expanding and economically costly new disease crisis.
To sum up, the social, psychological, public health, and economic consequences from this epidemic are already tragic, and are expected to become much more severe in many parts of the world. The Thesis position holds that something dramatic must be done soon.