‘Tragic Victory’ in the Fight Against AIDS

There comes a point when there is enough critical distance from a tragedy for people to make jokes about it (“Other than that, Mrs. Lincoln, how was the show?”). It will ruffle feathers to say this, but in the United States we are reaching that point with AIDS.

Consider the recent big- budget puppet movie “Team America: World Police.” The film features a spoof on the musical “Rent” in which the film’s protagonist, Gary, star of the Broadway smash “Lease,” belts out a catchy show tune: “Everyone has AIDS! My grandma and my dog ‘ol Blue / The pope has got it and so do you / C’mon, everybody, we got quilting to do.”

Maybe it’s funny and maybe it’s not, but this satire of anti-AIDS activists and agitators wouldn’t even have been possible just a few years ago. The devastating toll of AIDS in the U.S. was still too near to allow for such callousness.

But the song’s humor draws huge guffaws from audiences today, in part because we’ve crossed a threshold here in the developed world: HIV infection -- while still terrible -- has been transformed from a death sentence into a chronic, manageable condition. Humor becomes possible as the tragedy of AIDS as it was experienced in the 1980s and early ‘90s retreats, slowly, from memory.

But it’s not clear that this is such a good thing. In the years ahead, AIDS probably will follow the path of some earlier deadly infectious diseases; it will fall from the developed world’s radar screen while it devastates the impoverished corners of the globe. AIDS will be the next malaria or tuberculosis.

Malaria was a serious problem for Americans in the first half of the 20th century. When the Tennessee Valley Authority was established in the 1930s, 30% of the Tennessee Valley population was infected. Prompted by such high malaria rates there and elsewhere, the U.S. government sprang into action and eradicated the disease from the country. But today, all but forgotten by Americans, this preventable and treatable disease continues to cause 300 million cases of acute illness and kills between 1 million and 2 million people a year, according to the Centers for Disease Control and Prevention. Almost all of them are in the developing world.

It’s a similar story with tuberculosis. The “white plague” has been described by some experts, like Dr. Lee Reichman, executive director of the New Jersey Medical School National Tuberculosis Center, as the AIDS of its day.

The disease hit Victorian-era artistic circles -- which were concentrated in major cities like London and New York -- particularly hard. The developed world responded with anti-TB initiatives that almost completely wiped out the disease from Europe and the U.S. Decades later, the developing world isn’t so fortunate: The World Health Organization estimates that TB kills between 2 million and 3 million people a year.

The successful fights against malaria and TB are tragic victories. By successfully ridding the wealthiest parts of the globe of these plagues, they no longer trouble us even as they ravage millions around the world.

Is there any way to prevent HIV/AIDS from being the next tragic victory in global health? Perhaps. And the answer may come from what we learn from TB. Inadequate TB treatment efforts, particularly in places like the former Soviet Union, are prompting the disease to morph into one that is difficult to treat with current technologies and methods. Given Russia’s border with Europe, a costly and deadly multi-drug-resistant TB outbreak there could focus the wealthy world’s attention on diseases of poverty once again.

Something similar may be happening with HIV/AIDS. The WHO initially promoted and then withdrew the use of untested fixed-dose combinations of anti-AIDS drugs. The fear is that this ham-handedness could lead to strains of the AIDS virus that are resistant to current treatments coming back to haunt a developed world that thought it was beginning to get the disease under control. That would be no laughing matter.