The AIDS Pandemic
How do diseases become a pandemic?
New epidemics, when you see a new epidemic, think societal change. They go hand in glove. I like to give an example right in my backyard. When I was a boy I never saw deer. I can't get rid of them in my backyard now, the forests are shrinking. The deer come into the yard, the deer have ticks, the ticks carry the agent of Lyme disease, so we have Lyme disease as a modern phenomenon. That epidemic of legionnaire's disease was associated with something relatively new, air conditioning. The great influenza epidemic of 1918-1919, the war, World War one, military barracks. Polio in the fifties, early fifties especially, answers, I don't know. I wonder about the swimming pools that my mother used to talk to me about, they were becoming commonplace, public swimming pools. Someone must know that answer and I'm ashamed to say I don't know. But usually there's a societal change.
How did AIDS become a pandemic?
The historians tell us, it's not really history, it's recent. People in rain forests and rural areas started to migrate cities when the colonial European powers were leaving Africa somewhat abruptly. I guess this could be coupled with [someone] and famine and warfare. The bottom line is there was an increase in the population in the cities equatorial Africa somewhat dramatically. There were truckers on their routes going through these areas from rainforests. So rainforests came to town. How did it get global? What can anyone of us say happened after World War II? Tourism, money for tourism. Increased travel, increased sexual contact where you couldn't have them before. Probably increased sexual promiscuity. Intravenous drug use, the insanity of that phenomenon coming worldwide. For the first time in history, to my knowledge, blood moving from one nation to another.
Is AIDS worse than the bubonic plague?
The question is, is this virus the worst ever? And I try to make a comparison to plague or the great influenza epidemic and generally I say I don't know how you evaluate the comparison, it's like apples and bananas. One is like the tornado that comes through and kills everything in site, but leaves. HIV is more like a chronic thunderstorm with lightening bolts striking sporadically and never goes away, what's worse?
How common is HIV or AIDS in America?
Depending who you are and where you are. Where this institute sits, there's a very significant epidemic near here. So parts of Baltimore, parts of almost every where in urban America in big cities, have a deep problem. The rates of infection are high, so not far from where you're sitting right now, in central and western Baltimore, there's sometimes 8 to 10 percent of the population infected, which is like many of the African countries, that are doing very very poorly. What about Washington DC ? New York? Miami? San Francisco? Los Angeles? Detroit ?. I can't go through every city, I find it a little disheartening, not helpful to me in trying to do something about it, to keep track of this all the time. I know it's bad where I am.
How common is HIV or AIDS in the world?
I'll give you what I am told. It's a statistic that anyone can get from UNIAIDS. Approximately 30 million dead, and approximately 40 million infected. The statistic that impresses me more is one that was given to me by my colleague and the head of our epidemiology program, William Blackmer. He once gave me a slide to use. It's one of the few -- two or three -- epidemiology slides I would show in a public lecture. That slide points out that 180 to 200 thousand people died in the tsunami. Not that it shouldn't have obtained great publicity, but you'll agree that it got great publicity. When the slide was prepared, 258 thousand people died every month of AIDS. So, a tsunami every month. It doesn't get that publicity, right?
Why do certain countries have a higher rate of HIV and AIDS?
The reasons different countries have much higher incidence are multiple, complex and partly unknown. The ones that I would be aware of I could suggest to you. One; if it's a central African nation, they've been exposed longer, more time. Certainly you can tell that the virus is older there because there are more strains of it, which means more time to evolve. So they have more time of exposure. Second; inadequate testing of the blood for medical purposes. Where it came earliest here and we had the epidemic fairly recently. Here meaning the United States and then most European nations, though not all. Most of the industrial world, it came and it's still coming last to the people who need it the most. Three; less therapy, more people running around with a higher virus, more transmissibility. Fourth; gets into social studies. Is there anything due to any differences in cultural practices? Anything that exposes you to blood would certainly augment. Anything that leads to unprotected sex with more than the partner would certainly increase risk. Fifthly; ulcerative lesions facilitate transmission. If your partner was infected but also had a herpes ulcer, or an ulcer from another venereal disease, your risk of transmission is much greater. It is known but not yet completely understood that circumcision helps a woman not get infected if the male is circumcised. Circumcision is more common in industrial western world then it is in Africa for example. All of those are reasons that we have reason to believe, rather than genetics or something else.
What are the future predictions for AIDS mortality?
I know a curve, a graph that shows that if we don't do something in Botswana drastically you can look at the risk of dying of AIDS for a fifteen year old boy in Botswana was somewhere over eighty percent. And you can look at these statistics . . . now Botswana was the worst of the risks for the future in terms of death from AIDS. But on that chart that was going up to eighty, to ninety percent for Botswana there were a lot of countries as you come down, fifty, forty, twenty, thirty, you know, all in the range. Many countries, many of them in Africa, some are in Asia. That graph stays in my mind all the time.
Why is basic research important to AIDS?
Well, I can answer that question by telling you, increasingly there's stress. At least I see it. People thinking that the money should go towards behavioral research, towards social studies, towards education, towards, you know, just getting the drugs to people, and all the practical things. And they are right, that that's very, very important, but never at the expense of basic research. It's important to remind people that every, single, practical advance we have in AIDS, every single one. Therapy, blood testing, which makes education possible, public health possible, the whole thing is possible. All came from basic research. We need it for preventive vaccine, we need it for new therapy, which, surely we're going to need as we get more and more drug resistance. That's why we need basic research. They shouldn't be at each other's throat. They should be complimenting, and fighting for each other.
How has AIDS research helped other sciences?
I like to think of it in this way, that AIDS did have - to use the hackneyed expression - a silver lining on the dark cloud. The silver lining is in two ways some good came out of AIDS. Certainly for science some good came out of AIDS that was original in AIDS; basic immunology for sure; infectious disease for sure; molecular biology. Of all things we never expected that new molecular mechanisms never known before came out of HIV research. We have been surprised. I think, it has given some impetus to the role of viruses and human cancer also because of HIV by promoting the greater reproduction of other viruses that can cause tumours has led to certain kinds of tumours becoming more common. So even in cancer research AIDS leads the pack for anti-viral therapy. It is shown that you can treat anti-viral diseases. We didn't have treatment for anti-viral diseases. Now we have the pharmaceutical industry with a much more open mind to treat other viral diseases. With other viruses we had prevention by vaccine or nothing. Now you have no viruses. If you understand enough about them you can target them. So that is a spin off. I think it has given a new breath to the intensification of vaccine research also.
What positive social changes have occurred due to AIDS?
On a social side, I believe there are positive spin offs. The first one that I tend to think of is a greater tolerance for differences in people's sexuality. Number one. I've seen it before my eyes repeatedly. Number two, a greater contact between North and South, certainly with American and Africa, and greater good that is occurring because of it. A third one, that my colleague Tim McCoy reminded me of is women's rights and women's empowerment. In Africa, for example, it's on people's minds and maybe throughout the world where there may not be empowerment of women's rights. Those are three social areas in addition to a multiplicity of scientific things. That will be one of the good legacies of the HIV pandemic.
