Have we learned anything after 20 years of AIDS? Call for a National Health Board

Abstract

DONALD P. FRANCIS, MD, DSCa Jonas Salk wrote before his passing that the evolution of modern man would be conditioned more by survival of the wisest than the more traditional Darwinian predictions of fitness.' In turn, it has been said that wisdom accrues from repeated errors and the acquisition of understanding from those errors. If such is true, then an examination of public health's (and, indeed, society's) response to the AIDS pandemic over the past 20 years would give us some insight into our errors and, in the end, add to our wisdom. Over the last 20 years, as our scientific understanding of AIDS epidemiology has accumulated, the picture of the evolution of the epidemic has become quite clear. Human immunodeficiency virus type 1 (HIV-1), it appears, is an ancient virus of chimpanzees2 that is likely to have infected humans repeatedly for centuries as these animals have been hunted and butchered in central Africa. Those who inadvertently became inoculated through the butchering no doubt died of their disease, as may have their sexual partners. In pre-industrial Africa, the epidemiologic conditions were not aligned for expanded spread, and these deaths were likely attributed to tuberculosis or other wasting syndromes. It was not until the early 1970s that the conditions became ripe for worldwide spread of this dangerous virus. At that time, large numbers of male workers migrated to African urban centers, and female sex workers followed them. In this new setting, the sexual activity of a chimp-infected worker would have dramatic consequences. No longer would a small outbreak in distant communities remain isolated. The world was a different place. Airplanes allowed infected people to arrive in other world centers in a matter of hours. And in these distant centers, new social environments had developed that were perfectly designed to rapidly expand a sexually and blood-borne infectious agent. Gay men were frequenting commercial sex establishments, or bath houses, and intravenous drug users clustered around commercial needlesharing establishments, or shooting galleries. All of these changes in patterns of intimate contact in Africa and elsewhere in the world added immense