The Epidemic: A Global History of AIDS

Writing a book about the history of anything is an ambitious undertaking, and this book is no different. For those of us who witnessed HIV from the beginning of its recorded history, Engel does a good job of hitting the highlights and examining the issues.

The book’s introduction starts in Africa in the 1930s and summarizes the purported evolution/mutation of simian immunodeficiency virus and its accompanying species jump from monkeys to humans. There is certainly enough written about the origins of AIDS to support this hypothesis, and after all, HIV did not just appear in 5 young men in Los Angeles in 1981. The virus had to start somewhere.

With that out of the way, Engel digs in and tells the story in 326 pages. Not much is left out. He does a very effective job of describing the pain, panic, and uncertainty of the early days of the epidemic when theories abounded as to cause, modes of transmission, and who really was at risk.

In an atmosphere of fear of contagion, the fact that HIV was a sexually transmitted pathogen was lost to what the media referred to as “the general public.” Who are the members of the general public? Everyone who did not have AIDS is probably the operative definition from the early 1980s.

The emerging epidemic in Africa provided a direct contradiction to the epidemiology of HIV in the industrialized world. The sobering facts of the heterosexual epidemic in Africa remained footnotes for many years as we as care providers tried to deal with a public health crisis while ignoring the facts that were in front of us. While the conservative agenda included talk of quarantine, funding limits, and closing of gay bathhouses, gay political activists were, in some ways, their own worst enemy. Engel quotes Gay Liberation Front founder Jim Fouratt: “The problem that gay leadership refused to confront until recently-the sex issue, the lifestyle issue-created a vacuum for the homophobic moralists.”

The breath of fresh air that everyone had been waiting for arrived in 1985 in the form of the newly appointed Surgeon General, C. Everett Koop. Underneath his dry, stern faade lurked a public health iconoclast. In his 1987 report on the state of AIDS in the United States, Koop put AIDS into the public health framework that was so badly needed. His pamphlet Understanding AIDS, which tried to give a balanced approach to the critical issues-sex, condoms, abstinence, and sex education-not discussed in polite conversation, or anywhere else for that matter, was distributed to every household in the United States.

While funding for the AIDS agenda increased steadily in the early years, it was never enough. Later, as the demographics of HIV shifted to minority and underserved populations, another generation of Americans who failed to learn from the past was forced to confront the harsh reality that HIV had become their problem as well.

The second half of the book examines the global issues in depth. AIDS in Africa takes center stage here. However, AIDS in Asia, the Russian Federation, and India, as well as the cultural and economic factors that determine the risk and responses to what has become the HIV pandemic, is also covered.

Along the way, Engel highlights where we have risen to the occasion and succeeded (eg, early safe sex campaigns for men who have sex with men, the evolution of combination antiretroviral therapy). He also points out the blemishes, most notably our sluggish response to HIV testing. Reading chapter 4 was particularly sobering as he chronicled the movement for more widespread HIV testing that started as early as 1987, which was rejected for many reasons.

The Epilogue summarizes the past and looks to the future. Engel suggests that if the early public health response had been more coordinated and less politicized, we might find ourselves in a different place today. Public health and politics still collide today in many places. Two notable examples are the 31 states that still require special written informed consent for HIV testing, and politicians who “play doctor” and downplay the importance of condoms as one tool for disease prevention.

While none of us as individuals will discover a cure for AIDS, each of us needs to contribute to the effort in our own way. The future of the HIV/AIDS pandemic is in our hands, and the next generation deserves the opportunity to build on our strong effective leadership today.

William M. Valenti, MD
University of Rochester School of Medicine and Dentistry
Rochester, NY