Several years ago, healthy young men began to die in largenumbers from an unknown disease. As so often happens in thehistory of medicine, the early cases were considered isolatedextremes in the normal spectrum of an illness and there was, inretrospect, an inadequate appreciation by the health professionof a growing disaster. Slowly, but inexorably, the numbersafflicted grew and an insidious outbreak exploded into afrightening epidemic.
People who had been previously healthy developed rare tumors andunusual infections. Studies showed that they suddenly andinexplicably lost their normal immunity to disease. They had anillness for which medicine had no name, and in our ignorance wecalled it Acquired Immune Deficiency Syndrome - or AIDS.
More and more cases have been recognized since AIDS was firstseen in 1979-80. At first, most of the victims were homosexualmen in New York City and California, but soon heterosexualHaitians and drug addicts were diagnosed as having AIDS. Thenrecipients of blood, particularly hemophiliacs, fell before thepuzzling epidemic.
There were many questions and few answers.
Concern led to fear, then panic. There were demands for drasticaction, but no one was quite certain what to do. Federalofficials seemed to approach the epidemic with embarrassment,declaring that the problem was a local issue; local authoritiesclaimed they could do little without national support. Words andmeetings became a substitute for rational action. Politicianshandled the epidemic with unaccustomed wariness. Almost withoutexception, public leaders evaded the epidemic issue, avoidingeven the usual expressions of compassion and concern. Thevictims' sexual orientation apparently made involvement risky,and the politicians directed their courage and energieselsewhere. Still the young men continued to die. As of April 13,1,339 people have been diagnosed as having AIDS - 505 cases werefatal. In New York City alone, there have been 595, with 228deaths. As the disaster escalated, the organized medicalcommunity was strangely absent. When a fatal infection struckdown veterans attending an American Legion convention, healthprofessionals across America joined in the search for a solution.When women using tampons became ill with toxic-shock syndrome,medical centers immediately focused their enormous talents onthat problem. But when the victims were drug addicts and poorHaitian refugees and homosexual men, no major research programswere announced. Until it became clear that the disease couldspread to the general population through blood transfusions,organized medicine seemed part of a conspiracy of silence. Butthere have been many instances of individual courage, of simpleadherence by physicians and nurses and technicians to a code asold as medicine itself. Clinical medicine is not built on heroicdeeds but on steady, loyal service to patients. When they aredying in large numbers and when the mode of transmission of theirdisease is unknown, the daily routine of involved health workersassumes a quiet dignity and decency that deserves specialrespect. The clinician has a privileged role in an epidemic, forhe shares the victims' sufferings, despair and dwindling hopes.Added to the medical challenge has been a growing crisis inhospitals and social service departments faced with large numbersof AIDS patients. Because of the need for "isolationprecautions," every facet of care - nursing, nutrition,laboratory work, housekeeping, etc. - becomes extremely costly.The duration of an AIDS hospital stay is usually measured inmonths, and hospital bills exceeding $100,000 occur with everincreasing frequency. Health insurance coverage for the young andpoor is usually inadequate, often nonexistent. Society had notplanned for this epidemic. To address some of these problems, agroup of nationally known medical specialists recently gatheredin New York City for a symposium on AIDS with the hope that theirshared knowledge and experience might suggest promising avenuesof investigation for researchers, lend practical aid toclinicians and chart a course out of this crisis.
The history of medicine assures us that, with time and effort,the terrible mystery will be unraveled and a cure found. Whenthat day comes, we may look back and reflect with the samesatisfaction that Albert Camus's character Dr. Rieux, in "ThePlague," experienced as the epidemic finally vanished from Oranand he "resolved to compile this chronicle, so that he should notbe one of those who hold their peace but should bear witness infavor of those plaguestricken people; so that some memorial ofthe injustice and outrage done them might endure; and to statequite simply what we learn in time of pestilence: that there aremore things to admire in men than to despise."
Kevin M. Cahill is director of the tropical disease center atLenox Hill Hospital.
MEDICINE AND HEALTH; EPIDEMICS; DOCTORS