I wish that I had had this to read before the HIV/AIDS pandemic arrived.
For Epidemics and Ideas shows how epidemics evoke a series of recognisable
reactions and responses from society beyond the specifics of pathogen, place
or time. It is a very modern book, which successfully brings together history,
anthropology, sociology and other so-called social sciences with medicine,
or at least with public health. It goes far beyond the earlier appreciation
of the relationship between human society and diseases (as in Hans Zinssner’s
classic, Rats, Lice and History, Papermac, 1985, now out of print), to illustrate
the thesis that epidemics create substantial challenges to the medical/health
establishment, as well as to the political and social status quo. For the
concept of an epidemic is a social construction, which both reflects and
will help to determine public and private response to its rise and fall.

Epidemics and Ideas brings a vast specialised literature about past
epidemics and the response of societies to them within reach of the general
reader. The introduction and 11 chapters have four major strengths.

First, each chapter is an interesting, self-contained account from different
places and periods including classical Athens, the European Middle Ages,
medieval Islam, early modern Hawaii, early 20th-century India and later
20th-century Africa. Secondly, each chapter carries forward and illustrates
the central theme that epidemics exacerbate pre-existing tensions within
society and challenge the medical, political and social status quo.

Thirdly, the editors have ensured that the chapters are linked so that
the chapters refer to each other and feel complementary despite the diversity
of authors and topics. Finally, I must congratulate the authors – and editors
– on the uniform clarity of the chapters, each of which sets forth a question
or situation, proceeds to tell the story and makes the point in a highly
engaging manner.

It would be difficult for many readers today (and impossible for this
reviewer) to read such chapters as ‘Plague panic and epidemic politics in
India, 1896-1914′, ‘Epidemics and revolutions: cholera in 19th-century Europe’,
or ‘Syphilis in colonial East and Central Africa: the social construction
of an epidemic’ without making connections immediately with HIV/AIDS. Yet
few people working on AIDS had any previous experience either with a major
epidemic or with the history of medicine, society and epidemics.

It is not surprising that despite excellent books like Allan Brandt’s
No Magic Bullet (Oxford University Press, 1987), most HIV/AIDS experts spoke
and acted without a conscious awareness of relevant historical experience,
as if AIDS were an unprecedented phenomenon. Yet even this misperception
turns out to be a rather regular feature of the public-health response to
epidemic disease.

All the features of our modern pandemic emerge in the elegant historical
portraits in this book. There is the blaming of minorities (in Ancient Athens);
the search for purification of society (dragon-slaying in medieval Europe);
the co-mingling of fear and pity in attitudes towards the poor and marginalised
populations (plague in early modern Italy); the ways in which discussion
of the epidemic functioned as a surrogate for debate about major societal
issues (medieval Islam); the fear among the vulnerable that the epidemic
is a plot unleashed by the powerful (India); and resentment towards the
medical profession and reluctance of authorities to inform people about
epidemics through fear of creating panic (cholera in 19th-century Europe).

Yet of all the lessons of the past, perhaps the most chilling is found
in the superb chapter on plague in India in the late 19th and early 20th
centuries. When plague first struck India, both Indians and English living
in India were affected, and one of the most energetic and coercive public
health intervention programmes ever conceived was aggressively launched.
Yet once cases among the English declined, and despite the continued major
increase among Indians, plague was declared endemic and the resources vanished.
The Indian plague story also suggests that the official control programme
may have caused as much damage as the disease itself.

If it were not possible for all officials, health workers and other
people concerned about HIV/AIDS to read the entire book, at least the lucid
introduction and the chapters on cholera in Europe, plague in India and
syphilis in Africa should be required reading.

Historians have the luxury of using the ‘retrospectroscope’. Today we
are attempting to look into the uncertain future of the global HIV/AIDS
epidemic. Like history itself, this book does not contain any simple answers.
But it will provoke creative reflection, and the world needs all the insight
it can muster.

Jonathan Mann is professor of epidemiology and international health
at the Harvard School of Public Health. Previously he headed the Global
Programme on AIDS at the World Health Organization.

Yet just as AIDS forces us to reconsider the ‘status quo’ of health
and social systems thoughout the world, highlighting deficiencies and revealing
the limits of our knowledge and current practice, so the HIV/AIDS pandemic
has challenged epidemiology itself.

Epidemiologists have so far studied the sexual transmission of HIV in
four, independent ways. First, when AIDS was discovered, epidemiologists
described several ‘risk groups:’ gay men, intravenous drug users, people
with haemophilia (and other recipients of blood), and Haitians in the US.
Increasingly, studies focused on ‘risk behaviours.’ ÐÓ°ÉÔ­´´s sought to
identify specific behaviours, such as anal and vaginal sex, and quantify
their association with sexual transmission of HIV.

In the third stage, a highly productive period of epidemiological research
developed from the search for ‘biological risk factors.’ Factors affecting
the sexual transmission of HIV included: the presence of other sexually
transmitted diseases; the stage of illness in the infected partner, or how
suppressed his or her immune system had become; and in men, a lack of circumcision.
In the fourth stage, more recently, epidemiological thinking has broadened
to consider ‘societal risk factors,’ involving the social, economic and
political context of sexual behaviour.

In this process, epidemiologists have sometimes created strong controversy.
Here we focus on a single aspect of that debate, the consequences of identifying
the so-called risk groups.

Let us consider the process. ÐÓ°ÉÔ­´´s had identified a new, mysterious
and fatal health problem. In a climate of great uncertainty regarding the
cause of that disease rapid epidemiological study was urgently needed. A
working definition of the condition itself was used to help develop the
‘who, where and when,’ of epidemiological description. Certain categories
for describing the ‘person’ were adopted; the categories were considered
useful to the extent that identified ‘cases’ fitted within them.

In AIDS, the speed and effectiveness of intitial epidemiological analysis
was impressive: initially, over 97 per cent of known AIDS cases slotted
into the established categories. At that stage, scientists had not developed
blood tests so we had no information on the people who were infected with
HIV without illness. Epidemiologists’ analysis by risk groups provided the
first indications about how the disease spread and helped to identify people
at increased risk of AIDS. Blood donor deferral, based on risk group concepts,
substantially reduced HIV transmission. Health workers talked to affected
communities and were able to begin combating people’s denial of the reality
of the disease.

Yet ultimately the risk group approach was of limited use to epidemiologists,
and worse, had important adverse effects on society. The idea of risk groups
encouraged people to see AIDS as another person’s problem; it was easier
to deny the epidemic’s importance when the threat seemed restricted to a
few, presumably small, apparently well-defined groups. Second, the focus
on male homosexuals tended to reinforce society’s stereotypical views of
heterosexual and homosexual identity, rather than emphasising what is common
to all sexual behaviour. Oversimplifying the risk concepts probably contributed
to society’s denial of the reality of heterosexual transmission on HIV.

Also, while the risk groups defined in the US were not identical to
those in sub-Saharan Africa, the general perception that AIDS and male homesexuality
were inevitably linked may have delayed some government’s willingness to
acknowledge and respond to AIDS in their own countries. Finally, the fear
associated with AIDS, linked to groups already marginalised and suffering
from prejudice, likely reduced society’s tolerance of members of such groups.

So the risk group approach has had important costs, to both individuals
and society. In the face of a new and dangerous health problem there may
not be a radically different, initial epidemiological approach which would
not also hamper collection of vital knowledge. Nevertheless, we can refine
existing practice as a result of the HIV/AIDS experience.

Whenever a population already suffering social discrimination is involved,
epidemiologists must be acutely aware of the limits to the risk group approach
and the potentially negative impact of ‘risk grouping.’ In such a setting,
we can take three specific steps in the interest of public health. First,
and perhaps most importantly, intensive discussions with members of the
apparently affected populations must begin immediately. In this way epidemiologists
can develop a more refined and accurate understanding of the relevant factors
(behaviours, locations, timing) with minimal delay. Epidemiologists will
not be familiar with all cultures; talking to people involved can help in
selecting and expressing categories of highest value to scientists and public
health.

Second, the definition of categories should be explicitly discussed;
descriptive categories should be as precise as possible and avoid generalising.
It is essential to remember that the public will perceive the problem through
the eyes of the media; accordingly, the media must be helped to understand
the intitial findings in a responsible manner.

Third, just as evolution from ‘risk group’ to ‘risk behaviours’ and
‘societal risk factor’ involved the beneficial interaction of diverse scientific
disciplines (especially social science), so epidemiologists should work
with researchers in other disciplines at the earliest opportunity.

This is only part of a broader agenda involving the relationship of
epidemiological researchers, the people they study and public health workers.
We are reconsidering and debating issues of how to inform individuals, protecting
confidentiality and the short-and long-term responsibilities of researchers
to individuals. As epidemiology confronts other major behaviour-based health
problems, these topics will be increasingly important.

THIS MOST recent book from the Panos Institute is ambitious and important.
While many books have already been written about the pandemic of human immunodeficiency
virus, or HIV, infection (the ‘first epidemic’) and the clinical illnesses
which follow (the ‘second epidemic’), this is the first effort to synthesise
experience of the ‘third epidemic’ of reaction and response to HIV and AIDS.

In choosing a global perspective and in focusing on the social impact
of HIV/AIDS, the Panos Institute has rendered a great service. It presents
many examples of fear, prejudice and discrimination from different countries
and varied socioeconomic and political settings, with a mixture of technical
accuracy and readability which characterises the best of Panos’s work. Yet
the book manages to avoid oversimplifications that would have compromised
both its integrity and its value to the reader. For the villains – ignorance,
fear and also prejudice – are not bounded by any specific social, economic
or political system.

Despite its focus on the painful and counterproductive wave of discrimination
that has accompanied the HIV/AIDS pandemic, the book avoids a dogmatic or
grindingly negative perspective. In all three epidemics, there are many
heroes; in citing many positive and supportive responses to HIV/AIDS by
individuals and communities around the world, the book presents some of
the real-life complexities of the third epidemic.

The Third Epidemic has many additional merits. It underscores the importance
of HIV/AIDS in Asia, where a major epidemic is emerging. This epidemic,
presently centred in Thailand, Myanmar (Burma) and India, has great importance
for the future of Asia. In the chapters on Africa, South America, the Caribbean,
Europe and Asia, The Third Epidemic allows local voices to speak. One of
the most beautiful and eloquent of these voices belongs to the Brazilian,
Herbert Daniel, author of a remarkable book of essays, Life Before Death.

References to various World Health Organization documents are informed
and appropriate. And the graphic presentation is also excellent, including
pictures, drawings, marginal quotations and shaded boxes which present supplementary
or background material in a way that does not interfere with the flow of
the basic text.

In presenting The Third Epidemic, Panos has once again rendered a service
to the fight against AIDS. This new book is unique, and most helpful and
stimulating to the general reader as well as to the ‘AIDS specialist’.

During the past several years, the Panos Institute has made several
important contributions to the global effort against AIDS. Its previous
books, AIDS and the Third World and Blaming Others, its monthly publication
and its series of seminars for both journalists and nongovernmental organisations
have helped considerably to inform and mobilise awareness about the HIV/AIDS
pandemic.

Panos’s many admirers eagerly await its next dossier on AIDS.

While the anecdotes used in this book are well selected to illustrate
the range of settings involved, from the workplace to the family, from Europe
to Asia, the necessary reliance on individual stories inescapably limits
our full understanding or appreciation of the various phenomena involved.
The lack of adequate data remains a problem for all who are concerned about
the epidemic of prejudice and discrimination towards HIV infected people
and people who practise so-called ‘risk behaviours’. Thus far, with the
exception of catalogues of laws adopted in different countries, no agency
or institution has systematised data collection in this area, nor developed
criteria by which we may assess local, national or international efforts
to prevent discrimination. As in so many other human rights issues, a failure
to seek or collect information may act to reinforce the discrimination.

The focus of this book is social and societal. This strength is also
a limitation, for there is relatively less time for discussion of the context
for social behaviour – psychological, economic and political. Yet one of
the fine qualities of The Third Epidemic is its capacity to stimulate new
or additional thinking on these matters.

For example, the book provides several useful insights regarding preconceptions
that exist prior to specific prejudice against AIDS. This is an extremely
important issue. In surveys of public opinion and knowledge from around
the world, between 10 and 25 per cent of respondents claim that HIV can
be casually transmitted.

This belief may be critical in generating fears that can lead to prejudice
and discrimination. Yet this belief persists despite major information efforts
designed to convey the technical facts about HIV and how it is spread.

The refractoriness of ingrained belief to new knowledge merits study:
indeed, the third epidemic should stimulate renewed efforts to develop a
serious research agenda on the roots of our prejudice.

Jonathan Mann is former director of the Global Programme on AIDS, World
Health Organization.

While many links in the story are not known, we may reasonably assume
that HIV has existed, somewhere, for a long time. Precisely why it broke
out of its restricted habitat, sometime in the early to mid-1970s, is unclear.
Yet by 1981, when the disease AIDS was first discovered, HIV had already
reached five continents, and the pandemic was well underway. By the mid-1980s,
when the global scope of the HIV/AIDS problem was recognised, there was
a worldwide alert and national and international efforts were mobilised.
By 1987, AIDS had become the world’s first truly global health concern.

Let’s look again at some features of HIV/AIDS which made it, in retrospect,
more easy to recognise. One of these is that while the latency period from
initial infection to AIDS averages between 8 and 10 years, some infected
people develop AIDS two to three years after infection. If the latency period
had averaged 15 to 20 years, or if hardly any infected people had become
visibly ill before 10 years had passed, detection of the HIV/AIDS pandemic
would have been much delayed.

The fact that AIDS affected young, healthy people in a few urban areas
in an industrialised country with an excellent national disease surveillance
system (the United States), was a second feature of HIV/AIDS which made
it easier to detect than it might otherwise have been.

Further, AIDS showed itself by causing very rare infections; clusters
of Kaposi’s sarcoma and Pneumocystis carinii in young people were so unusual
that they rapidly sounded the alarm. Had AIDS simply caused an increase
in common diseases, it would have taken much longer to realise that a new
problem had emerged.

Finally, the first human retrovirus (HTLV-I) had been recently discovered,
in the later 1970s. Laboratory methods to detect and study these viruses
had just been developed when AIDS was first reported. Had the science of
human retrovirology not already existed, many more precious years would
have passed – with severe consequences for public health – before the viral
cause of AIDS was identified.

These specific features of the new worldwide HIV epidemic were critical
for its relatively rapid detection – which in turn led to an unprecedented
global effort in prevention and scientific research. Any further delays
in recognising AIDS could have translated into millions of additional HIV
infections worldwide. It is, therefore, important for us to ask some pointed
questions about the spread and detection of disease in the modern world.

Throughout history, our world has offered viruses and other pathogens
an unparalleled opportunity for rapid global spread, as diseases have spread
along routes of trade and communication. The bubonic plagues of the 1st
and 14th centuries, for example, spread to Europe along the road from central
Asia, while Columbus and those who followed him brought measles and other
diseases which decimated the native populations of the New World.

Yet never before in history have so many people travelled to so many
faraway places so frequently as today. International tourist arrivals have
increased over 15-fold since 1950, and this does not include the many undocumented
travellers whose numbers can only be surmised.

The sheer volume of movement of people and goods, across all borders,
has created a qualitatively new situation which is ideally suited to the
global spread of disease. In a world in which a commercial soft drink can
reach isolated villages across continents, viruses and other infectious
agents can expect virtually unlimited travel potential. HIV may be the first
virus to take advantage of this uniquely modern opportunity, but it would
be a fatal error to assume it is the last.

How can we catch the next pandemic in time? Before dismissing this idea
as science fiction, we should remember that exactly 10 years ago, HIV was
still completely unknown and undetected, yet spreading silently around the
world. Even today, the next pandemic may already be underway.

My purpose is to draw attention to an objective condition of the modern
world which AIDS has highlighted – and to propose a global pathogen watch
to protect us all.

A global pathogen watch is exactly what it says: a system designed,
as rapidly as possible, to pick up evidence of the circulation of new pathogens
or the movement into new areas of already known but geographically restricted
pathogens.

Such a concept poses great conceptual and logistic difficulties. After
all, it is one thing to count cases of a known, easily diagnosed illness
like smallpox or bubonic plague. It is quite another challenge to watch
out for something which, by definition, we do not know! Furthermore, who
will pay for and operate the system which might be set up? This is a new
challenge. We must be creative in responding to it, and learn as much as
possible from psychology, anthropology and history. We should invest now
in creative thinking about how a sensory network can be created that will
be capable of seeing what has not been recognised before, and sometimes
to listen – like Watson and Holmes on the moors – for the bark which doesn’t
occur. A traditional, passive surveillance system would almost certainly
miss the mark.

In addition, we could strengthen communication networks among health
systems worldwide. We could make an inventory of all known pathogens to
assess their capacity for spread beyond their present territory. And we
can ask yet again: what system could have been capable of detecting AIDS
in 1975 instead of 1981? If the challenge or expense seems too great, we
should consider the cost, in human and financial terms, of delays in detecting
a pandemic like AIDS. How much could have been saved if AIDS had been detected
in 1975? How much more would have been lost if the disease had escaped detection
until 1985 or even until 1990? The history of AIDS is telling us something
very important about disease in the modern world. The tragedy of AIDS will
be even greater if we fail to heed this global lesson.