Book Review

The Epidemic: A Global History of AIDS

N Engl J Med 2007; 356:969-970March 1, 2007

Article

The Epidemic: A Global History of AIDS
By Jonathan Engel. 388 pp., illustrated. New York, Smithsonian Books/Collins, 2006. $28.95. ISBN: 978-0-06-114488-2

The epidemic of the human immunodeficiency virus (HIV) and AIDS has become the Rorschach epidemic. Popular accounts often reveal more about their authors than about HIV and AIDS, which are relegated to supporting roles in service of some broader agenda. The Epidemic is an exception to this trend. Through a painstaking medical, cultural, and political narrative, Jonathan Engel largely lets the story of HIV and AIDS speak for itself, from its emergence in 1981 through the present. His only real themes are that AIDS is neither message nor metaphor — it “simply is, as are we” — and that attempts to politicize or co-opt it have in many cases done more harm than good. But he is careful to separate fact from argument, and one need not accept his premise to benefit from his history.

Three stories emerge most forcefully from this book. The first concerns the cultural revolution that the epidemic sparked in gay communities. Gay liberation brought about an explosion of high-risk behavior, and by 1980 homosexual men accounted for more than half the cases of syphilis and gonorrhea in the United States. The subsequent spread of HIV then prompted an almost equally rapid reversal. Most gay men swiftly reduced the number of sexual partners they had and increased safe-sex practices, and by 1987 new cases among gay men were already declining. This behavioral change — accomplished in an era before the advent of wonder drugs, big money, or red ribbons — marked the first successful counterattack on the virus. Beyond this, AIDS also galvanized homosexuals to redouble the fight against discrimination, nurtured a strong sense of responsibility, and gave rise to the gay marriage movement. In its wake, public opinion toward homosexuals has improved markedly.

The second story recounts the multifaceted national response to the epidemic. Although political leaders were slow to embrace the issue, Engel shows how medicine, activism, and celebrity involvement converged to move AIDS quickly up the policy agenda. By 1987, AIDS was receiving the most federal money per patient of any infectious disease and inducing numerous changes in health policy. Engel considers some of these changes salutary. One example is the speeding up of the drug-approval process by the Food and Drug Administration, wherein a process that had once taken an average of a decade was accelerated for AIDS drugs as patients pressed for greater influence over the decisions on which their lives depended.

A View from the Washington Monument in Washington, DC, of the AIDS Memorial Quilt, October 11, 1996.

Regarding other changes, Engel is more critical. His greatest concern lies with what he sees as politics sidelining science. He disparages the political right for demonizing the afflicted and impeding effective measures to reach them. But he also argues that the left, in portraying HIV as an equal threat to everyone, produced public health campaigns “ill matched with the actual risk profile of the population.” He concedes, though, that there was a substantial benefit to fund-raising and public awareness. He also faults gays and civil libertarians who blocked the use of traditional public health tools, such as testing, reporting, and partner notification. There remains an active debate as to whether such measures could have worked in the early years of ubiquitous stigma and suspicion.

The third compelling theme of the book concerns the uncertain future of AIDS in America. On the one hand, Engel lauds dramatic medical gains, notably antiretroviral therapy, which he adjudges to be a “miracle” for having reduced AIDS-related mortality. On the other hand, he warns that HIV is still growing among minorities, especially blacks, who now account for half of new infections in the United States. Its continued spread has been facilitated by lingering homophobia in black communities and the resulting silence about AIDS. Equally disturbing, risky behavior has resurged among homosexual people of all races, with new infections of HIV and other sexually transmitted diseases rising in lockstep. These developments are sobering reminders that social norms remain central even in an age of medical marvels.

The subtitle notwithstanding, this book is not a global history. Brief chapters nicely distinguish the epidemics in Africa and Asia from those in the West, but the global discussions are too cursory to reflect the depth and diversity of AIDS around the world. Like many books about AIDS, The Epidemic also suffers from publishing lag. Its pessimism about the prospects for treatment in poor countries, for instance, is rapidly being belied by events. Its lack of a bibliography and heavy reliance on press reports will also limit its usefulness to scholars. Overall, however, anyone seeking a thorough and engaging chronicle of the AIDS epidemic in America, rich in detail and data, will find much to esteem here.

Keith Hansen, M.P.A., J.D.
World Bank, Washington, DC 20001
khansen@worldbank.org