AJPH First Look, published online ahead of print May 2, 2006
June 2006, Vol 96, No. 6 | American Journal of Public Health 958
© 2006 American Public Health Association
Death and Hope
Stewart Landers, JD, MCP, Associate Editor, Senior Consultant
John Snow, Inc, Boston, Mass
For the baby boomers who lived through big events—the Kennedy assassination, the Vietnam War, Watergate—and who witnessed or participated in the progress of various liberation movements—civil rights, women’s liberation, and gay rights—the June 1981 report of the first mysterious illnesses among homosexual men did not register as a seismic event. Even to most gay men, this ominous report was a far-off drumbeat, alarming yet distant. The tsunami of death that was about to envelop the gay community did not appear likely to affect anyone outside this relatively small, effectively marginalized group. How wrong! HIV soon spread anywhere and everywhere that blood, breast milk, semen, and vaginal fluid went.
The first bit of hope appeared relatively quickly, in 1984, when the HIV virus (née LAV/HTLV-III) was identified and the antibody test was developed. By 1985, the blood supply was being screened. Transmission became understood and the gay community’s sexual behavior showed evidence of dramatic change. The community’s allies—lesbians, chosen families, and, sometimes, birth families—became caregivers who helped victims through the dying process, offering solace and hope.
Before the first prevention efforts were conceived, the long HIV latency period left a time bomb of death ticking among gay men, hemophiliacs and other transfusion recipients, injection drug users, women who partnered with individuals at risk, newborns, and, perhaps most ominously, pockets of heterosexual communities in the United States and beyond that seemed to manifest no known risk behaviors.
Hope again offset death with the approval in 1987 of the first drug found to have any effectiveness against HIV—zidovudine, known commonly as AZT. While the drug extended the lives of most AIDS patients only briefly, it proved effective in reducing mother-to-child transmission of HIV and jump-started aggressive pharmaceutical development. Nine years and 300 000 American deaths later, highly active combination antiretroviral therapy (HAART) produced miraculous results. In the wealthier nations, there was cautious rejoicing that a fatal diagnosis had morphed into a chronic illness.
The early epidemic among heterosexuals was a foreboding of the vast number of deaths to occur; HIV had spread across the globe, with particular haste in the resource-constrained nations of sub-Saharan Africa. As "managing" the epidemic became the byword in resource-rich nations, a wave of death such as had not been witnessed for generations engulfed one country after another. In 2000 alone, 3 million died, and a staggering 40 million individuals were infected worldwide.
In the face of this cataclysmic plague, the world responded. What seemed to be beyond imagination—bringing life-saving drugs to the most destitute people on the planet—moved from idealist fantasy to all-out effort. Somehow, individuals inspired organizations and organizations led nations to unite to fund this massive mobilization of human, medical, and capital resources. Hope was kindled in every corner of the world.
Does the next quarter century mark the endgame of this struggle between death and hope, or more repetitions of the cycle? Can treatment actually be delivered to all who need it? Will effective biological tools to prevent HIV infection be found? How will millions of deaths affect orphans, vulnerable youth, fragile cultures, and global security? It does not bode well that patients in many states within our own borders languish on waiting lists for HIV medication. The struggle between death and hope wages on.
Copyright © 2006 by the American Public Health Association
