Thursday, 7 October 2010

The Epidemic, Jonathan Engel

The Epidemic, Jonathan Engel
Smithsonian Books

At some point in the first part of the twentieth century, a huntsman in what is now southern Cameroon had an encounter with a chimp.  He may have fought with it and been wounded.  He may have killed it cleanly and then cut himself while butchering it.  A few people think that he had sex with it.  Whatever - the result was that an odd and obscure virus jumped species to homo sapiens, and the seed was planted of the greatest epidemic of our time.

The Acquired Immune Deficiency Syndrome was first publicised and named in the United States.  The existence of the terrifying new disease was formally announced in a low-key article in a routine bureaucratic report in June 1981 (it had been mentioned in print for the first time in a New York gay newspaper the previous month).  The syndrome affected mainly gay men in New York, Los Angeles and San Francisco, where a distinctive and highly sexualised gay culture had developed in the 1970s.  It was not a pleasant way to die.  Alongside the gay victims there emerged an unlikely combination of haemophiliacs, female prostitutes, intravenous drug users - and, rather bafflingly, Haitians.  Meanwhile, doctors in Europe had begun to observe strange, untreatable diseases in a few patients who came from or had worked in sub-Saharan Africa.  They heard reports that their American colleagues had come across something similar and were classifying it as a disease of homosexuals - those crazy Americans, always so obsessed about sex!

But it was mainly a gay disease in America - and increasingly in Britain and Germany too.  It was like something out of a horror movie.  Gay men suddenly found that thousands of their number were infected with a lethal virus which had no known cure.  They reacted with horror and desperation.  The Reagan administration was a prominent target of criticism (something of a flavour of this emerges from Randy Shilts' And The Band Played On and the spinoff HBO film).  There was an upsurge in homophobic incidents. Undergraduates at Dartmouth celebrated Rock Hudson's death with a sorority party.  Health insurers refused to cover male hairdressers and florists.  In the later 1980s, anti-gay sentiment began to enter the mainstream, perhaps catalysed by the 1988 elections.

Some gay activists played a dangerous game, angrily rejecting attempts to change their community's sexual mores.  For the most part, however, the gay community acted resolutely enough to reduce transmission rates significantly by the mid-to-late 1980s, while infections became more prevalent among IV drug users and their (heterosexual) partners - though, of course, the virus's long incubation period meant that this cultural change came too late for many.

The virus was discovered in 1983, and was initially called LAV or HTLV-III, depending on who you asked. Its discovery was either ably assisted or else set back a year by the American celebrity scientist Robert Gallo, and its existence was announced in 1984 by Ronald Reagan's health secretary Margaret Heckler. She predicted that a vaccine would be available within two years.  Within the Reagan administration, there was palpable distaste at dealing with a disease that seemed to affect mainly promiscuous homosexuals and drug abusers - though honourable mention should go to Dr Everett Koop and Admiral James Watkins, two Reagan advisers whose fastidious Christian distaste for such things did not stop them from taking a hard-headed and practical approach to the epidemic.  In Britain, the Thatcher government adopted uncharacteristically liberal AIDS policies, though the Iron Lady did intervene personally to change a reference in a newspaper advert from "anal intercourse" to "back passage intercourse".

Engel notes that AIDS, contrary to many worried predictions, never became a heterosexual pandemic in the West.  In Africa, however, the story was very different.  The virus had originated in Africa, before apparently being transported by Haitian migrants from Zaire to their home country and then brought into the US through gay networks.  The virus was already quite well entrenched in Africa by the first half of the 1980s.  The drivers behind the African epidemic seem to have included the mobility of migrant workers, local cultural attitudes to sexual activity, and a high prevalence of other STDs (which made it easier for HIV to be transmitted).  The epidemic disproportionately affected educated middle-class professionals, a feature that gave it broader social and economic implications.

HIV has a number of biological features that make it a particularly difficult pathogen to treat, and its long incubation period allows it to spread itself widely before it kills its host.  The search for a cure has proceeded steadily, albeit more slowly than Margaret Heckler predicted.  In 1987, the American Food and Drug Administration granted approval to AZT, a drug so feeble that it prolonged life expectancy only by a year and at the same time so toxic that some patients actually preferred AIDS to its side-effects.

By the end of the 1980s, the pharmaceutical arsenal was slowly growing.  In 1996, effective antiretroviral therapies became available.  These were initially primitive and cumbersome, requiring multiple doses at specific times of the day.  Some of the drugs in the cocktail had to be kept refrigerated, while others had to be taken on a full stomach, or on an empty stomach, or with milk.  The side-effects were still a problem.  But antiretrovirals revolutionised the treatment of HIV in the West, and turned it from a death sentence into a serious, chronic but manageable illness.  Thousands of men and women were suddenly confronted with the prospect of living for years or decades longer than they had expected - and, in some cases, of unexpectedly having to pay off enormous debts or having to retire on underfunded pensions.  Meanwhile, millions of HIV-negative people began to let their defences down, or even, unbelievably, to actively court infection.  In the developing world, access to antiretrovirals became a sensitive political and commercial issue, and Engels deals sensitively with the various arguments and pressures surrounding it.

Overall, Engel tells his story well and backs it up with solid research and evidence. He appears to be coming from a moderately conservative perspective.  His judgement on the Reagan White House, for example, is less hostile than that of most AIDS activists at the time, albeit far from laudatory.  He has no time for homophobic conservative responses to the epidemic, but he is not writing from a civil libertarian perspective either.  There are a few mistakes and inaccuracies.  He doesn't say much about the very early history of the virus, and some of what he says is a little inaccurate (and slightly out of date by now - the book was published in 2006).  In all, however, this is a serious and impressive work of medical and social history, and a respectable addition to the HIV/AIDS literature.