Author: Randy Shilts
Widely acknowledged as the definitive account of the history of AIDs, this book charts the course of the epidemic as it swept across the world, with a focus on America in the 1980’s. It is an exhaustive record of the impact of HIV on the homosexual communities of San Francisco and New York, the major epicentres of the plague. The book depicts HIV’s almost clandestine arrival, its initial silent spread, and the bleak period that followed as it ferociously struck down its victims, a time when ‘the brightest moments…tended to do little more than illuminate how truly dark the future would be’ (page 457). The book also documented the roles, both positive and negative, played by the politicians, physicians, health agencies, and the media, who influenced the course and outcome of the outbreak. The author’s vivid portrayal of the ravages of AIDS was matched only by the stridency of the criticisms he levelled against those charged with controlling it (page 213). The overall picture he painted was a mosaic of ‘courage as well as cowardice, compassion as well as bigotry, inspiration as well as banality, and redemption as well as despair‘ (page xxiii).
Central to the book’s narrative is the ‘raucous‘ homosexual lifestyle of San Francisco at the onset of the epidemic, ‘a city in which two in five adult males were openly gay‘, and a place where indulgent sexual practices flourished (page 15). His characterised the city’s famous sex clubs and bathhouses, where the clientele were provided with ‘unlimited sexual opportunity’, as ‘biological cesspools of infection‘ (pages 154 and 86). This exceptional promiscuity was symbolised by the more than 1,000 lifetime sexual partners a typical homosexual man contracting AIDS would have had at the time (page 132). This permissiveness was illustrated by Gaetan Dugas, the Canadian airline steward who had about 250 sexual contacts a year, and found San Fransisco to be a convenient place to ‘satisfy his voracious sexual appetite’ (page 22). Considered to be patient zero of the AIDs epidemic, he also earned the sobriquet, ‘the Quebecois version of typhoid Mary‘; this is because he continued his prolific sexual activities even after his diagnosis, often calmly telling his partners afterwards that he had gay cancer (pages 83, 147, 157 and 200).
A compelling feature of the book is its detailed exploration of the impact of AIDS on its victims. Using graphic stories, the author illustrated the exceptional devastation of a disease which left its victims looking ‘as though they had been dragged out of some sadistic concentration camp‘ (page 86). A typical victim was Nick who initially presented with a seizure, and his head scan revealed massive brain lesions caused by toxoplasmosis. He subsequently developed disseminated cytomegalovirus (CMV), and eventually died on a respirator in intensive care (pages 41, 45, and 53). Ken Horne was another symbolic example; although he died of Kaposi’s sarcoma and pneumocystis pneumonia, his autopsy showed that he ‘had withstood infections far beyond what his doctors had imagined’, from cryptococcal pneumonia to cytomegalovirus (pages 65 and 100). Mark Feldman, another casualty of AIDS, ‘died a particularly gruesome death’ with excruciating herpes sores in his mouth, Kaposi’s sarcoma lesions covering his insides, and pneumocystis protozoa filling his lungs (pages 208-209 and 318).
As much as the book addressed the clinical and social repercussions of AIDS, it also mapped its epidemiology, tracking its intriguing sources and phenomenal spread. The author traced the origins of the virus to Africa, illustrating this with a vivid account of the first documented case, the Danish surgeon Grethe Rask, who worked on Zaire and died of pneumocystis pneumonia in 1977 (pages 3-7 and 277). The book also described the two waves of AIDS that struck Europe, the first one heterosexually transmitted and from Africa, and the second one predominantly homosexual and from New York (pages 193 and 261). The author identified the 1976 bicentennial celebration in New York as the likely temporal epicentre of the American epidemic; this was probably the time when the virus infected countless revellers, and then used them as vehicles for widespread transmission (page 142). The book also explored the second phase of American AIDS which involved heroin addicts, haemophiliacs, Haitians, and house staff, who, along with homosexuals, made up the 5 H’s risk groups. Secondary infections later manifested in the female sexual partners of infected men, and children of heroin addicted parents (pages 121, 261, 197, 225, and 339). The Haitian link was particularly interesting because it had its roots in Africa: it came via Haitian workers who had worked in Zaire, where they had been hired to replace Belgian workers who had been expelled from the country (pages 135 and 392-393).
Alongside the deeply human perspectives of the book, the author also described the intensive research and medical efforts that went into identifying and controlling HIV. The race to determine the nature of the virus, eventually successful, was nevertheless tainted by the seething rivalry that pitted the French team of eventual Nobel prize winners, Luc Montagnier, Jean-Claude Chermann, and Francois Barre, against the American virologist Robert Gallo, ‘inarguably, one of the nation’s foremost retrovirologists‘ (page 201). The author outlined how the French correctly identified HIV as a member of the lentivirus family of retroviruses, but they struggled to convince the scientific community who believed Gallo’s claim that he had isolated a human T cell leukaemia virus (HTLV) as the responsible agent of AIDS; rather scandalously, the virus Gallo ‘isolated’ turned out to be the same one the French had previously sent to him to analyse (pages 229, 270, 319, 409, 450-452, and 528-530). On the clinical front, the book cited the efforts of several physicians who played central roles in the epidemic. These included Selma Dritz, a public health expert who reported a high frequency of gastrointestinal diseases linked to oral-anal sex; Michael Gottlieb, an immunologist who first made the link between pneumocystis pneumonia and T cell deficiency; and Jim Curran and Don Francis of the Centres for Disease Control (CDC) who coordinated the early epidemiological assessments of the epidemic (pages 38-39, 42-43, 56-67, 71-73 and 80-81).
The most disturbing feature of the history of the epidemic that the book documented was the failure of political institutions, health agencies, the media, and the public to act promptly and effectively to confront AIDS. The author asserted that AIDS ‘was as allowed to happen by an array of institutions, all of which failed to perform their appropriate tasks to safeguard the public health’ (page xxii). He illustrated the failure of political will and leadership when he pointed out that in April 1983, ‘AIDS policy in New York would be little more than a laundry list of unmet challenges, unheeded pleas, and programs not undertaken‘ (page 276). The author, a journalist who covered the epidemic very closely, was incensed at how little funding was made available for AIDS research, and how frequently the few scientists working on the AIDS epidemic came up against ‘the indifference of science, government, mass media, most gay leaders, and public health officials’ (pages 463 and 171). He argued that this widespread nonchalance was attributable to the universal disdain with which homosexuals were perceived by society (page 110). He rued the fact that despite so much knowledge of AIDS in 1983, the apathy did not relent until the film star, Rock Hudson, disclosed his diagnosis of AIDS (pages 331 and 575- 582).
This is a monumental piece of work that set out to document every relevant event related to the HIV epidemic. It stands out for its scrupulously chronological account of the epidemic’s progress. A masterclass in assessing emerging epidemics, the book is brimming with lessons in how to develop and test hypotheses, and how authorities should avoid prevarication and provide sufficient and prompt research funding. The book emphasises the importance of developing treatments early, and it highlighted the priority of health over political and cultural concerns in doing so. The author’s detailed chronological approach, documenting almost every landmark in the course of the epidemic, increased the length of the book. This feature however probably contributes to the book’s authoritative reputation, and enhances its value as a reliable historical account.
AIDS was the most important epidemic of the last century, and this book extracts from it several important lessons for healthcare. It highlights the importance of early detection of epidemics, prompt epidemiological studies to establish its nature, and adequate funding for research, public health, and drug development. The emphasis on the political and public failures in tackling AIDS serves as a potent reminder of the pitfalls to avoid when faced with future epidemics. The book details the dedicated commitment of a few physicians to their patients, and to the protection of public health; this is worthy of emulation by healthcare, and I recommend the book to all doctors.
Publisher, Place, Year: Souvenir Press, London, 1988
Number of chapters: 259
Number of pages: 630
Star rating: 5