WE'RE ALL RIGHT JACK, BUT...



Published in slightly different form in Tomorrowsf (http://www.tomorrowsf.com), No. 11 (November-December 1998).

Thomas A. Easton



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On August 15, 1998, newspapers around the country reported the headline on the previous day's Bay Area Reporter: "No Obits." (Click here for the story that appeared in the San Jose Mercury News.)
The Bay Area Reporter is a weekly gay newspaper in San Francisco. For years, it has reported the deaths of AIDS (Acquired Immune Deficiency Syndrome) victims, and the week before that headline was the first in seventeen years when it had no such deaths to report to its readership. No one pretended that this meant the AIDS epidemic was over or that death had taken its little holiday anywhere except San Francisco, but the nation's newspapers seemed to breathe a palpable sigh of relief. The tide had turned. New medications and new combinations of medications had made it possible at last to control HIV (Human Immunodeficiency Virus) infections. HIV-positive people were taking longer to develop AIDS, and AIDS patients were taking longer to die. And perhaps people were finally getting the point about risky behaviors.
It's true, too. We have made immense progress against this disease. Yet it is well worth bearing in mind that San Francisco is a very tiny portion of the world, and what happens there is by no means reflective of what is going on in the rest of the country. And that country--our fondly regarded United States of America--is only a part of the developed world, which in turn is distinctly outnumbered by the developing world.
That is, there's a lot of world out there. There's a lot of AIDS, too, and most of the papers out there (where there are any) can't say, "No Obits" at all.
The global story is not reassuring. Indeed, it's downright alarming. To see just how bad the situation is, you can download the UN's June 1998 Report on the Global HIV/AIDS Epidemic, which presents data as of the end of 1997. (If you wish to see the data for specific countries, click here for national fact sheets.)
In 1997:

Look at those death stats: 11.7 million over the nearly 20 years that the epidemic has run. Some 600,000 per year, on the average. And nearly four times that many in 1997. "HIV has more than doubled the adult death rate in some places," says the UN report. "[It] is the single biggest cause of adult death in many others.... [It] is among the top ten killers world wide, and ... may soon move into the top five, overtaking such well-established causes of death as diarrhoeal diseases."
There is no danger that AIDS will solve the population problem for us. That problem stems from a surplus of births over deaths--including AIDS deaths--of about 90 million per year, and besides, AIDS victims live long enough to reproduce before they die. The numbers therefore do not paint a picture of an epidemic on the wane. We are NOT winning! To say that we are, based on the statistics from a very small portion of the world, whose people are blessed by wealth enough to afford cutting edge treatment, is to deny the greater part of reality.
On the global level, says that UN report, "The human immunodeficiency virus (HIV) continues to spread around the world, insinuating itself into communities previously little troubled by the epidemic and strengthening its grip on areas where AIDS is already the leading cause of death in adults ... Unless a cure is found or life-prolonging therapy can be made more widely available, the majority of those now living with HIV will die within a decade. These deaths will not be the last; there is worse to come. The virus continues to spread, causing nearly 16,000 new infections a day. During 1997 alone, that meant 5.8 million new HIV infections, despite the fact that more is known now than ever before about what works to prevent the spread of the epidemic."
So how can we congratulate ourselves on "No Obits"? The simple answer is that we are a rich nation, and even though we and our developed-nation friends are a minority on this Earth, we tend to think that we are the whole of humanity, or at least the part of it that counts. This lets us dismiss as essentially irrelevant statements such as "89% of people with HIV live in sub-Saharan Africa and the developing countries of Asia, which between them account for less than 10% of global Gross National Product" (and therefore cannot well afford prevention and treatment programs, although Uganda and Thailand--for instance--have made great strides in controlling their epidemics).
Africa has it worst by far. In some countries, a fifth or more of the population carries HIV. "Over two-thirds of all the people now living with HIV in the world--nearly 21 million men, women and children--live in Africa south of the Sahara desert, and fully 83% of the world's AIDS deaths have been in this region." Transmission is--as it has been all along here--primarily through heterosexual contact, and women are a large proportion of the victims. "Four out of five HIV-positive women in the world live in Africa." As a consequence, Africa is home to most of the AIDS orphans, too.
The developed world is in much better shape. In 1997, new HIV infections were a mere 30,000 in Western Europe and 44,000 in North America, with the mode of transmission shifting toward drug users. Mother to child transmission was rare, unlike the case in Africa, partly because pregnant women can obtain antiretroviral drugs to minimize transmission at birth and partly because safe alternatives to breast feeding are readily available. New AIDS cases were down 38 percent in Western Europe. A 1996 drop of 6 percent in the US--the first ever in that country--was expected to be surpassed in 1997; the biggest drop (11 percent) was among gays, thanks to high levels of education and strong organization; the case count was still rising among minorities and the disadvantaged, partly because of inability to afford the drugs that offer some control for HIV infections.
Researchers have tried for years to understand why HIV and AIDS have stricken some countries worse than others. They have blamed both poverty and education levels, and certainly "most of the worst-hit countries are among the world's poorest" and least educated. Customs have also taken the hit, for the disease has spread rapidly among groups and peoples that are sexually promiscuous, heavy users of sex workers, or sharers of contaminated needles.
In sub-Saharan Africa, analysis reveals a strange relationship between HIV and literacy: "the countries with the highest levels of HIV infection are also those whose men and women are most literate," perhaps because "social changes that accompany more schooling are also associated with behaviour that increases the risk of HIV infection." Women, for instance, may be exposed to a wider "spectrum of social and sexual relationships." Educated men, with more income, may visit sex workers more often and fail to use condoms, at least "in the early stages of the epidemic, when information about the dangers of unprotected sex is scarce."
But this essay is not about why the AIDS epidemic has spread. Rather it is about recovery from the epidemic, and that very definitely seems to be a matter of money and education. Education helps by supporting efforts to get the word out about the kinds of behavior that make one vulnerable and the kinds that can protect one. Money helps in huge part by paying for public education programs (which alone can make a big difference, as it has in Thailand) and the drugs that keep HIV infections from progressing to AIDS and limit transmission to infants. Not surprisingly, the benefits are most visible in the developed world (though not necessarily among minorities and the poor).
Indeed, those benefits have accumulated to the point where a major American city's most vulnerable community can relievedly proclaim, "No Obits!" The rest of us can share in that relief, wiping the clichéed hand across the brow and sighing, "We're all right, Jack!"
And so we are. We are fortunate in a thousand ways compared to our brothers and sisters in Africa, Asia, Eastern Europe, and South America. See the World Health Report 1998. We can afford to put so much into prevention and treatment that we can reverse the tide, at least in our own lands.
If we forget that our good fortune is a minority experience, we are guilty of phenomenally limited thinking. To our shame, we can take the "if" off that sentence. Most of us don't think of ourselves as that fortunate--the way we live is the way everyone should live, and if they don't, that just proves how stupid, blind, obstinate, and/or savage they are. We take for granted those antiretroviral drugs for HIV, but they aren't much over a decade old.
We also take antibiotics, for instance, for granted, forgetting that they were discovered in this century. Many have already lost their usefulness thanks to the evolution of resistance in their targets, but they have been and remain immensely useful.
We also forget the diseases that used to plague us and still do plague the developing world. Remember that near the beginning of this column, I said that HIV's death toll could overtake "such well-established causes of death as diarrhoeal diseases"? That's right. Diarrhea. The shits. Go ahead and snicker. You can easily handle that touch of gastroenteritis with modern over-the-counter preparations and antibiotics, but without that sort of help it can be deadly because it dehydrates. In the US, it kills some 500 kids a year. In the developing world, where drugstores, OTC preparations, and antibiotics can be very hard to find or afford, it is a primary symptom of cholera, diphtheria, dysentery, and other diseases that kill millions every year. Indeed, in the developing world, infectious diseases account for 43% of the death toll (versus only 1% in the developed world). See also Global Microbial Threats in the 1990s.
And the developed countries just don't face the same problems the undeveloped ones do. Consider:

Click here and here to find still more tropical parasite and other diseases. Fortunately temperate winters limit the spread of many parasites into the developed world. Insecticides have helped us control malaria, yellow fever, and other diseases carried by mosquitoes. Food sanitation has licked roundworms, tapeworms, and trichinosis. Personal hygiene and frequent laundering beat pinworm. Wearing shoes has helped stop hookworm.
Clearly it hasn't needed immense wealth or advanced technology to shield us from some of what's out there. But much of the developing world can't afford even modest expenses for controlling infectious diseases and parasites. Their people die in numbers that make our self-satisfaction at "No Obits!" seem exceedingly parochial.
We could help the developing world by providing or funding drugs (for those diseases for which there are useful drugs), water treatment plants (billions lack access to safe drinking water and are therefore routinely exposed to parasites), or even rubber boots (to keep schistosomes and other water-borne parasites from burrowing into skin). We don't do this because the size of the problem--the US has less than 5 percent of the world population--is so immense that it quite overwhelms the ability of the developed world to fund the fix.
We could of course do more than we do, beginning with something as obvious as paying our massive arrears in UN dues. That we don't may be racism, as some accuse, but it seems more likely to be that parochialism. Short-sightedness. "We're all right, Jack," and the problems that plague others do not affect us.
Perhaps we should remind ourselves of John Donne's lines: "No man is an island, entire of itself ... If a clod be washed away by the sea, Europe is the less, as well as if a promontory were ... any man's death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee."


Dr. Thomas A. Easton is Professor of Life Sciences at Thomas College in Waterville, Maine. He has been the Analog book columnist for almost 20 years. His latest novel, Unto the Last Generation, is available only on-line, from Mind's Eye Fiction. Last year's Silicon Karma (White Wolf, 1997) was well received. His latest nonfiction books are Taking Sides: Clashing Views on Controversial Issues in Science, Technology, and Society (Dushkin Publishing Group, 1995, 2nd ed., 1997, 3rd ed., 1998) and Periodic Stars: An Overview of Recent Science Fiction (Borgo Books, 1997).

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