Dr. Stanley Monteith has a long and distinguished history of being wrong about AIDS epidemiology, and his latest contribution to the Medical Sentinel continues the tradition.
First, let's be straight about this little faux pas with the "iceberg" theory of AIDS epidemic growth which he concedes was wrong but doesn't explain. Specifically, he ignored the rule that all epidemics follow a bell-shaped curve, rising steeply at first, then more slowly, then flattening and declining. Instead he used a linear growth extrapolation to predict that by 1992, "we will have somewhere between 13 and 27 million people carrying the virus" in the United States. He then went on to ask, "what will happen with 50-l00 million American carriers?" Yet last year, CDC researchers estimated current HIV infections in this country at around 700,000. AIDS cases have plateaued, meaning infections must have plateaued many years ago. Deaths are actually on the decline though this is in part due to new drug therapies.
With the American AIDS epidemic having proven such a tremendous disappointment, Dr. Monteith now sets his sights overseas. He tosses around numerous terrifying figures concerning infection rates among Africans. But go to his notes and you find his sources are not medical or scientific journals, nor any health organization, but rather radio interviews with somebody named John Harris and somebody else named Peter Hammond. Who these people are we are not told. Obviously, if Dr. Monteith had more reliable sources for his data he would have used them. Other sources for Monteith's frightening data include "a missionary friend living in Africa" and "a missionary stationed in Johannesburg, South Africa." Not very impressive.
To paraphrase Mark Twain, the news of Africa's demise has been greatly exaggerated. My 1990 book, The Myth of Heterosexual AIDS, notes that a high Ugandan official stated in 1986 that within two years this country would be a desert, while newspapers ran such headlines as the 1987 one: "AIDS Epidemic Threatens to Depopulate Much of Africa." Yet a decade later, populations in all African countries continue to grow and deaths from age-old and curable diseases like tuberculosis and malaria continue to swamp those from AIDS. According to the World Health Organization (WHO), HIV infections have peaked in Africa. Like Monteith, WHO has a history of exaggerating the AIDS threat. If even that body admits African infections have peaked, they've peaked.
As to the new Asian sub-strain supposedly discovered by Harvard's Dr. Myron Essex, which he claims is much more easily spread through vaginal intercourse, his claim has not been verified. I believe that, like the claims of the researchers who said they had discovered "cold fusion," Dr. Essex's will never be verified. For at least a decade now, Dr. Essex has been telling us we're doomed to have a heterosexual AIDS epidemic in the United States, that indeed the smugness of heterosexuals "makes it certain that the infection will establish itself in the heterosexual population." His predictions of a devastating American epidemic, like Monteith's, have not materialized, and Essex has also looked overseas and predicts that someday this new sub-strain will make its way here and realize his dire predictions for the U S.
Yes, there are high rates of infection is some Asian countries, but no new sub-strain is needed to explain this. The reason HIV spreads more easily in places like Thailand (and Africa for that matter) than in the United States is because other sexually transmitted diseases that cause genital lesions run rampant there. These lesions have repeatedly been demonstrated to tremendously facilitate the transmission of HIV. Intravenous drug abuse is also a serious problem in Thailand.
Dr. Monteith criticizes my book, claiming it stated "there was no possibility of heterosexual spread in the United States." Curiously he offers no page number in his citation. Indeed, he cannot since the book never said that. Rather, it said that heterosexual infections would continue to be closely tied to intravenous drug abusers and to a lesser extent bisexuals, instead of going hetero-to-hetero-to-hetero. It said that heterosexual AIDS cases would always constitute a small proportion of an epidemic that was in itself in the process of flattening out.All this has proven true.
Far from stating that "no public health measures were needed," I vociferously argued that we needed to focus such measures on the persons truly at risk, rather than pretending (as Dr. Monteith did) that to use one popular slogan at the time "AIDS is an equal opportunity destroyer." Indeed, I spent an entire chapter just on the special problem of blacks and Hispanics. I not only agree with Dr. Monteith that many homosexuals, IV drug abusers and minority heterosexuals and children have needlessly died, but I was saying this in articles ten years ago - long before he was.
On the other hand, many of the public health proposals Monteith says should have been carried out would have been worthless. Indeed some, such as premarital HIV testing, were carried out in some states, did prove worthless, and were halted What was the purpose of testing persons who by the very nature of entering into marriage indicated that they were at low risk of getting HIV?
I am on record as favoring partner tracing, but it's of limited use. First, the infected index patient has to truthfully provide a list of partners. Second, he must know who his partners were. In the case, say, of the homosexual male who goes to bathhouses and has several partners in the course of the night, this is obviously problematic. On the other hand, people who frequent such establishments already realize that by the very nature of their sexual activities they must have become exposed to HIV-infected persons, so there's little point in telling them about any one specific contact.
Dr. Monteith urges us to use the syphilis paradigm in combating AIDS. But HIV is not syphilis, and fighting AIDS with public health measures designed to combat syphilis cannot be expected to work. Indeed, even the syphilis campaign of Surgeon General Parren that Monteith cites was far less effective than he and others would have us believe. As Allan Brandt notes in his book No Magic Bullet, it was drugs, especially penicillin, that really broke the back of the syphilis problem, not Dr. Parren's public health measures.
Ultimately, sad to say, this will also be the case with AIDS. The numbers will go down to an endemic level. But the history of syphilis and gonorrhea shows that people eventually make a psychological peace with sexually transmitted diseases, no matter how dire the consequences. The evidence is that young male homosexuals are already doing so with AIDS. Many homosexuals will continue to have unprotected sex; many drug abusers will continue to share their needles and syringes. And so AIDS will continue. We need to focus our efforts in these areas - in short, fight the fire where the flames are and not where the media says they are. But barring a highly effective vaccine or drugs that eliminate the virus from the body, this terrible problem will be around for a long, long time.
Mr. Fumento is the author of The Myth of Heterosexual AIDS and a former AIDS analyst for the U.S. Commission on Civil Rights. He is currently a resident fellow at the American Enterprise Institute, 1150 17th Street, N.W., Washington, DC 20036. e-mail: firstname.lastname@example.org.
Originally published in the Medical Sentinel 1997;2(3):106-107. Copyright©1997 Association of American Physicians and Surgeons (AAPS)