Philip Alcabes discusses myths of health, disease and risk.

AIDS Goes to Ground

This week, Donald McNeil, Jr. continues his praiseworthy efforts to highlight the sad reality of AIDS among the world’s poor.

In an article posted on the NY Times website Sunday (and published in the print edition Monday), McNeil reports on the inability of treatment programs in parts of Africa (this piece focuses on Uganda) to keep up with the need for AIDS medication as funding falls.   A very compelling video report accompanies the online version of the article.

An accompanying article explains the decline in funding, starting with the fall in the U.S. administration’s request on behalf of PEPFAR, as a Times graphic shows.

The number of new infections with the AIDS virus is estimated to be about 2 million per year now.  Some observers think annual incidence will rise as the population expands; even if not, the annual number of new AIDS virus infections is unlikely to fall in the near future, given present circumstances.

At the same time, the Times reports, anticipated PEPFAR funding is essentially flat to 2013, at $5 to $5.5 billion per year.  Financing for AIDS medications through the Global Fund to Fight AIDS, Tuberculosis and Malaria is in dire straits.

In terms of people, not dollars:  of the 33 million or so individuals who are infected with the AIDS virus worldwide, only about 4 million get regular antiretroviral therapy.

A few years ago, I wondered why,  after a quarter-century of AIDS and with the availability of effective treatment (at least in wealthy countries), Americans still didn’t see AIDS as an ordinary illness.

Now I have an answer:  we do see AIDS as ordinary… for poor countries.  To us, AIDS is no longer an epidemic problem worth our getting worked up over, or so it would seem judging by PEPFAR.  AIDS is like malaria, tuberculosis, or schistosomiasis.  It’s like diarrhea.  The Bill and Melinda Gates Foundation will put money into research or specific programs but we as a country will not need to care anymore.  We shift the funding away from the people in Africa, who are going to die young anyway, and put it into the hands of institutions (often, pharmaceutical companies) that can give us the promise of immunity from disaster.

The U.S. put less funding last year into PEPFAR than it did into preparations for H1N1 flu ($7.6 billion) or the school lunch program ($14.9 billion, according to the Robert Wood Johnson Foundation’s Center to Prevent Childhood Obesity), battleground in the war against childhood obesity.

Flu and obesity are epidemic.  They threaten American assumptions about ourselves.  “Epidemic” means:  crisis in our society.  Our epidemiologists say that malaria, diarrhea, and the other problems that collectively kill 20,000 or 25,000 people (mostly children) every day are endemic

“Endemic” means:  not our problem.

AIDS is endemic too, now.  It has gone to ground, gone the route of other once-dreaded infections that caused calamity in America and triggered heated debate (yellow fever, cholera, typhoid, TB) but have disappeared from our scene.  It’s their problem, now.

New Year’s Wishes for Public Health

May 2010 be the year when health officials return to the business of alleviating suffering and stop promoting panic. (Don’t miss Nathalie Rothschild’s “Ten Years of Fear” in Spiked!’s Farewell to the Noughties, recounting the hyped-up panics of the ’00s — from the Y2K bug to swine flu.)

May CDC become a force for real public health, not an advocate for the risk-avoidance canard.  May the new director, Dr. Frieden, stop favoring pharmaceutical companies’ profit making through expansion of immunization.  And may he direct the agency to begin to address legitimate public needs, like sound answers about vaccines and autism, and clear communication about what is — and isn’t — dangerous about obesity.

May WHO officials stop playing with the pandemic threat barometer.  May WHO begin demanding that the world’s wealthy countries devote at least the same resources to stopping diarrheal diseases, malaria, and TB as they do to dealing with high-news-value problems like new strains of flu.   Diarrheal illness kills as many children in Africa and Asia in any given week as the 2009 swine flu killed Americans in eight months.  So does malaria.   Direct policy, and money, toward sanitation, pure water free of parasites, adequate treatment of TB, mosquito control, and prevention of other causes of heavy mortality in the developing world — not just flu strains that threaten North America, Europe, and Japan.

May public health professionals lose their obsessions with bad habits. May the public health profession return to the problem of ensuring basic rights — access to sufficient food, clean water, decent housing, good education, a livable wage, and adequate child care — and ease up on its moralistic obsessions with nicotine and overeating (for recent examples of the preoccupation with tobacco, see this article or this one (abstracts here; subscription needed for full articles) in recent issues of the American Journal of Public Health).

May science be what Joanne Manaster does at her incomparable website: looking at the world with wonder, asking without dogmatic preconceptions how it works, and accepting that its irrepressible quirkiness makes it impossible to know the world perfectly.  May science not be the crystal-ball-gazing thing whose so-called “scientific” forecasts are really doomsday scenes worthy of the medieval Church — predictions of liquefied icecaps and rising seas,  hundreds of millions of deaths in a flu pandemic, or catastrophic plagues sparked by people with engineered smallpox virus.  There are plenty of reasons to be concerned about both the environment and disease outbreaks based on sound here-and-now observations; leave the forecasts of Apocalypse to the clergy, who know how to handle dread.

A new year’s wish (from the valedictory exhortation in Tony Kushner’s Angels in America):  “More life!”

It isn’t health if it isn’t for everyone

A couple of weeks ago we toured the Wildlife Health Center at the Bronx Zoo with Dr. William Karesh, director of the field veterinary program for the Wildlife Conservation Society and VP for WCS’s Global Health Program.

We learned that veterinarians from the Wildlife Health Center do rounds for all animals in NYC’s zoos and aquarium; animals needing special care are brought to the center.  Health records for all animals in zoos are electronic and are maintained with common software – making it straightforward for health records to be transferred whenever the animal is transferred from zoo to zoo, anywhere in the world, and of course facilitating research.

Animal health seems far removed from human health – not only in that it’s much harder for caregivers to see any person’s prior health records than it is for vets to see an animal’s.  We think of wildlife health as distinct from our own.  Even when an event like the 2001 foot-and-mouth disease outbreak in Britain causes us economic distress and affords people the ghastly sight of piles of cow carcasses piled up in farm fields, we don’t see the connections easily.

Increasingly, it’s becoming apparent that the health of human populations depends on equilibria in the wider world.  We have our military-style campaigns to defend Fortress Humanity from microbial invaders:  we use antibiotics, vaccination, and close monitoring of routes of ingress via food and water.  They work, at least up to a point.  But the evidence of MRSA, antibiotic-resistant TB, avian flu, S. Saintpaul in jalapeño peppers, and the new swine flu is that those measures aren’t perfect.  There’s not going to be any Conquest of Contagion (as Charles E.-A. Winslow put it in 1943),  and so-called victories such as the use of immunization to eradicate smallpox and control polio won’t be repeatable for every germ.

In the long run, as the One World, One Health movement suggests, we’ll have to shift to a much broader view of the planet as a system – in which we humans are co-resident with other species.  We might manage to ward off a serious flu outbreak with vaccine (the jury’s still out on whether the current swine flu strain can become highly damaging or not, but it’s reasonable to think that some flu strain might).  And we should improve food-safety systems to guard against outbreaks of salmonellosis and the like.  But we have to move toward a more complex understanding of how human health, animal health, environmental conditions, and international transfers of food, animals, goods, and people interact, especially with respect to the movements of microbes.

In that regard, it’s  troubling to learn from DemFromCT’s post at DailyKos yesterday that Sen. Max Baucus says that a new healthcare plan in the U.S. will not cover undocumented immigrants. It’s cruel, of course, to deny care to immigrants.  But it’s also shortsighted.

If we continue to have a huge, frequently mobile proletariat of migrant workers  forced by economic duress to travel from country to country in search of a living wage and we also make it impossible for them to get care, we’re harming ourselves.  Even those who aren’t moved by the humanitarian aim of ensuring all individuals a decent life should be moved by self-interest.  Creating a means by which disease and disability can move around with the people who suffer from them will undermine whatever arrangements we make for health.

One Health means we have to think about the interactions of many species – and it’s ridiculous to exclude some members of our own.

Disease Cycles: The Rebirth of Flu

Flu has taken on the resonance of other big diseases in the culture – autism, AIDS, breast cancer, and the like.  We don’t have a ribbon yet, or run/walk fundraisers, but what was once an everyday affliction has become an epidemic of interest.

Based on the evidence of the last few weeks, officials are going to be expected to generate substantial plans to curtail a pandemic whenever something out of the ordinary happens with flu – whenever they say that an outbreak can “no longer be contained.” And they’ll be applauded – as Margaret Chan is in a paean in yesterday’s NY Times – for (as Chan herself puts it) “managing a high pressure crisis … with a sense of urgency.”  Pharmaceutical companies will be urged (and paid, of course) to produce extra-large lots of vaccine and antivirals.

In other words, flu will have followed the pattern set by many other illnesses, both real and imagined.  We live with them for a time; we figure them as being among the countless travails of normal life; they’re unremarkable, even if lamentable. At some point, they seem to resonate with specific anxieties, and we become more attuned to their occurrence.  They become epidemic threats (or, with flu, a “pandemic threat”).

Tuberculosis had a trajectory like this – an unremarkable cause of suffering and death for centuries, until it came to be associated with ethereal spirituality.  Later on, TB took on a new resonance because of its association with poverty, which by the 20th century had started to carry an ideological flavor (or several flavors).

Syphilis had many meanings heaped on it, but it only came to be seen as a public health problem when the Progressive movement shaped it into a rationale for combining moralism with medicine, ca. 1900.  And syphilis became a social crisis after the Progressives’ approach called for epidemiologists to make sense of it (statistical findings always help craft the narrative of rising threat), and the new data helped to further the narrative of social failing and personal misbehavior.

The flu scene is thick with epidemiologists now, fogged with rumors about what went wrong, and filled with theories about causes.  This is exactly what it takes to create an epidemic.  Some people think that’s good, because more attention will be paid, and more funding appropriated, and we’ll be better able to “fight” flu.  That remains to be seen.  In any case, you have to wonder who is going to benefit, and what the price will be.