Infectious and Epidemic Disease in History

Department of History
University of California, Irvine
 Instructor:    Dr. Barbara J. Becker

Lecture 20.  HIV/AIDS.

October 1980 -- May 1981

  • new disorder of unknown origin is first described by Dr. Michael Gottlieb and colleagues at UCLA
  • five young previously healthy homosexual men were treated in local hospitals for Pneumocystis carinii pneumonia (PCP)
    • rare condition (only 5 cases in LA 1967-1978)
    • occurs almost exclusively in persons with severely suppressed or defective immune systems
June 1981
  • wrote up findings for CDC's Weekly Report:

Morbidity and Mortality Weekly Report [MMWR]
June 5, 1981 / Vol. 30/ No. 21/ pp. 250-252
Centers for Disease Control and Prevention

A Cluster of Kaposi's Sarcoma and Pneumocystis carinii Pneumonia among Homosexual Male Residents of Los Angeles and Orange Counties, California

In the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California.  Two of the patients died.  All 5 patients had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and candidal mucosal infection.  Case reports of these patients follow.

Patient 1:  A previously healthy 33-year-old man developed P. carinii pneumonia and oral mucosal candidiasis in March 1981 after a 2-month history of fever associated with elevated liver enzymes, leukopenia, and CMV viruria....  He died May 3, and postmortem examination showed residual P. carinii and CMV pneumonia, but no evidence of neoplasia.

Patient 2:  A previously healthy 30-year-old man developed p. carinii pneumonia in April 1981 after a 5-month history of fever each day and of elevated liver-function tests, CMV viruria,....  His pneumonia responded to a course of intravenous TMP/.SMX, but, as of the latest reports, he continues to have a fever each day.

Patient 3:  A 30-year-old man was well until January 1981 when he developed esophageal and oral candidiasis that responded to Amphotericin B treatment.  He was hospitalized in February 1981 for P. carinii pneumonia....

Patient 4:  A 29-year-old man developed P. carinii pneumonia in February 1981....  He did not improve ... and died in March....

Patient 5:  A previously healthy 36-year-old man with clinically diagnosed CMV infection in September 1980 was seen in April 1981 because of a 4-month history of fever, dyspnea, and cough.  On admission he was found to have P. carinii pneumonia, oral candidiasis, and CMV retinitis....

The diagnosis of Pneumocystis pneumonia was confirmed for all 5 patients antemortem by closed or open lung biopsy.  The patients did not know each other and had no known common contacts or knowledge of sexual partners who had had similar illnesses.  The 5 reported having frequent homosexual contacts with various partners.  All 5 reported using inhalant drugs, and 1 reported parenteral [injected] drug abuse....

Reported by MS Gottlieb, MD, et al., Div of Clinical Immunology-Allergy; Dept of Medicine, UCLA School of Medicine; I Pozalski, MD, Cedars-Mt. Sinai Hospital, Los Angeles; Field services Div, Epidemiology Program Office, CDC.

Editorial Note:  Pneumocystis pneumonia in the United States is almost exclusively limited to severely immunosuppressed patients....  The occurrence of pneumocystosis in these 5 previously healthy individuals without a clinically apparent underlying immunodeficiency is unusual.  The fact that these patients were all homosexuals suggests an association between some aspect of a homosexual lifestyle or disease acquired through sexual contact and Pneumocystis pneumonia in this population....

All the above observations suggest the possibility of a cellular-immune dysfunction related to a common exposure that predisposes individuals to opportunistic infections such as pneumocystosis and candidiasis.  Although the role of CMV infection in the pathogenesis of pneumocystosis remains unknown, the possibility of P. carinii infection must be carefully considered in a differential diagnosis for previously healthy homosexual males with dyspnea and pneumonia.

July 1981
  • Kaposi's sarcoma (KS) diagnosed in 26 male homosexuals in NYC and SF
    • rare cancer
    • usually confined to elderly males and immuno-suppressed transplant recipients

Kaposi's sarcoma
CDC had just completed a cooperative study with a number of gay community health clinics--a multiyear, multisite study of hepatitis B:
  • risk factors
  • patterns of sexual transmission
  • prevalence among homosexual men
Researchers found hepatitis B to be significantly associated with (among other factors):
  • number of sexual partners
  • sexual practices that involved anal contact

What are the patterns here?

How can these patterns be revealed?

What questions can be asked?

What questions should be asked?

How can researchers distinguish research bias from working hypotheses?

  • CDC established special task force on KS and opportunistic infections (PCP) to:
    • demonstrate that outbreak was, indeed, new (any similar cases before 1980??)
    • confirm whether it was targeting specific populations and geographic areas
    • verify all cases
July 1981
August 1981
  • all state health departments asked to notify CDC of suspected cases
June 1982
  • disease is called "Gay-related Immune Deficiency" [GRID]
  • it is found that 22% of patients with KS or PCP are heterosexual
July 1982
  • 32 Haitian immigrants found to have disorder
  • similar syndrome is noted in hemophiliacs
September 1982
  • name AIDS [Acquired Immune Deficiency] first used
    • defined as disease at least moderately predictive of a defect in cell-mediated immunity, occurring in a person with no known cause for diminished resistance to that disease
December 1982
  • infant that had received blood transfusion at birth falls victim to the disease; blood seen as possible source
March 1983
  • major shift in thinking about risk factors and transmission
  • emergence of virus as possible agent
  • research conducted by virologists at
    • Pasteur Institute in Paris (Luc Montagnier) and
    • National Cancer Institute in Bethesda (Robert Gallo)
First Steps toward Discovery of Human Immunodeficiency Virus [HIV]


  • Howard Temin finds that virus he is studying somehow incorporates the DNA of the cells it infects in its own reproduction
  • claim goes against commonly-held view of how cells reproduce


  • independently, Temin and David Baltimore discover a new class of virus--the retroviruses


  • Dr. Kiyoshi Takatsuki at Kyoto University studies a form of leukemia that causes a cancer of lymphocytic cells in the blood
  • calls this disease Adult T-Cell Leukemia [ATL]


  • Robert Gallo at National Cancer Institute isolates the first retrovirus known to cause cancer in humans
  • calls it Human T-Cell Leukemia virus [HTLV]


  • second retrovirus found; causes "hairy cell" leukemia [HTLV-II]


  • Luc Montagnier at Pasteur Institute in Paris isolates a new retrovirus which he calls lymphadenopathy-associated virus [LAV]


  • Robert Gallo at National Cancer Institute isolates a retrovirus believed to be agent responsible for AIDS; calls this virus HTLV-III
  • Researchers in San Francisco isolate AIDS-associated retrovirus [ARV] from AIDS patients in different risk groups
  • five papers appear in journal, Science:  4 by Gallo; 1 by Montagnier
  • researchers recognize that LAV, HTLV-III and ARV are the same
  • new name given to this microbe:  Human immunodeficiency virus [HIV]

HIV particles


Should HIV testing be compulsory???

Should HIV-positive individuals be required to register with local health officials???

Should the names of HIV-positive individuals be made public???

In 1999, two epidemiologists debated the question:

"Is confidential named HIV reporting a proper approach to fighting the epidemic in California?"



by Ralph R. Frerichs, D.V.M., Dr.P.H.

Dr. Frerichs is professor and chair of the Department of Epidemiology at the UCLA School of Public Health.



by Walton Senterfitt, R.N., M.PH.

Dr. Senterfitt is a practicing epidemiologist and health planner, longtime AIDS activist and Person Living With AIDS.

What's in a name?  A lot, when it comes to an unrecognized infections disease that spreads by intimate person-to-person contact.  While not difficult to prevent if detected, the human immunodeficiency virus (HIV) differs from other communicable diseases in two respects.  First, the virus is closely identified with gays, and has become entwined in gay political concerns such as open identification, discrimination and social acceptance.  Second, those who harbor the virus have become vocal and organized.  They serve as a strong lobbying force against legislative actions that limit their personal freedoms, which sometimes involve viral transmission.

HIV remains a cunning foe, difficult to treat and rid from the body, but not hard to prevent if the identity of the HIV-infected person is known.  In general, health departments in the majority of states that now have named HIV reporting (31 at last count, but not California) make good use of the identity of HIV-infected persons.  The gathered data are easily checked for duplication in count, thereby improving the quality of the surveillance system.  Contact is maintained with persons who are infected and their susceptible spouses or sexual partners.  Such susceptible persons can then protect themselves from HIV by avoiding sexual or blood contact, or by reducing their risk with condoms, withdrawal or use of clean needles.

For HIV-infected persons, treatment is an expensive long-term undertaking that requires follow-up and support beyond what is offered by busy physicians.  Having names helps health departments maintain such contact and encourages public support for the cost of therapy.  Finally, in the case of pregnancy, having a name allows medical and public health workers to ensure early treatment, necessary to preserve the life of the newborn child.  For these reasons, I strongly support named HIV reporting, along with confidentiality safeguards that are standard when dealing with sexually transmitted diseases.

One-third of HIV-infected persons in Los Angeles County are not aware of their infection.  Of those who do know, at least 25 percent are not receiving care.  Named reporting will do almost nothing to help identify and assist these persons, who contribute most heavily to the continued spread of HIV.

A small but significant proportion of individuals will decline testing or services if their names are to be confidentially reported to an agency of the state.  The actual risk of disclosure by public health staff is infinitesimal, but this is beside the point.  Fear, regardless of whether it is founded in reality, is the main barrier to testing and care.  Public health must address the continued social stigma underlying these fears.  Instead, advocates of named reporting have fueled fear, even if unintentionafly.  They have tactically allied with political forces indifferent or hostile to HIV/AIDS care and to the people who are living with AIDS.  Such tactics alienate the HIV-infected and affected communities, whose massive involvement in advocacy, prevention and social support has been a powerful engine of progress against HIV.

Fundamentally, emphasizing named reporting diverts our attention from what would really work:

  • Extend access to care to all, for real.
  • Vastly expand voluntary HIV testing, using new technologies and new venues.
  • Establish sensitive, community-based partner counseling and referral services.
  • Create acceptable transrnission-prevention programs for HIV-infected persons.
  • Supplement surveillance with sampling and modeling to periodically estimate the prevalence and incidence of HIV in the total population.

With treatment advances rendering AIDS ever more arbitrary, we do need expanded surveillance to monitor and plan.  A non-name-based unique identifier system can meet this need, with only modest loss of efficiency.

What do you think?


The "Rule of 48"

All Scientists Are Blind

... some years before [Peter Leavitt] had formulated the Rule of 48.  The Rule of 48 was intended as a humorous reminder to scientists, and referred to the massive literature collected in the late 1940s and the 1950s concerning the human chromosome number.

For years it was stated that men had forty-eight chromosomes in their cells; there were pictures to prove it, and any number of careful studies.  In 1953, a group of American researchers announced to the world that the human chromosome number was forty-six.  Once more, there were pictures to prove it, and studies to confirm it.  But these researchers also went back to reexamine the old pictures, and the old studies--and found only forty-six chromosomes not forty-eight.

--Michael Crichton, The Andromeda Strain (1969;1993), p. 125.
"Usually the number of chromosomes is constant in a given species, although it may vary between different species even of the same genus.  In man the chromosome number is forty-eight...."  [Human Genetics and its Social Import, by S. J. Holmes (1936), p. 8.  The illustration above appears on p. 9.]

"... the number of chromosomes is in general constant for any given species.  Thus in each cell of a human being there are 48 chromosomes (24 pairs)...."  [Principles of Heredity, 3rd. ed., by Laurence R. Snyder (1946), p. 26.]

Exploring Biology:  The Science of Living Things, 5th ed., by Ella Thea Smith (1959), p. 503.  An additional note on this page reads:  "Improved methods of counting chromosomes seem to indicate that the diploid number in man may be 46 rather than 48."

"If you learned your biology a long time ago, you learned that men have forty-eight [chromosomes]--but the number has now been revised downward to forty-six (twenty-three pairs)."  [The Language of Life:  An Introduction to the Science of Genetics, by George and Muriel Beadle (1966), p. 89.]

When and how did the change in the count of human chromosomes take place?  Here's a first hand account from biologist, Maj Hultén, who was then an undergraduate student in Stockholm:

I was walking in the culvert linking the Institute to the Animal House, carrying my mouse cages.  It was late at night the day before Christmas Eve, on December 23, 1955, when I suddenly heard the clapping (and echoing) sound of clogs behind me, and a heavy hand landed on my left shoulder.  I got mighty afraid, but recognizing it to be the diminutive Chinese visiting scientist, Joe-Hin Tjio, I wondered what on earth this was all about.  "I can see that you are equally kind to everybody around here.  Would you like to come to my room?  I have got something interesting to show you", he stuttered.  "Yes, please", I found myself answering.

Peering down the microscope, situated on the bench to the right in Tjio's office cum lab, I was amazed to see the human chromosomes well spread out and separated from each other, and when Tjio demanded:  "Count", I did so.  My first comment was "You have lost two", but then in metaphase after metaphase there could be no doubt, the chromosome number was 46.  It was a cliché to say that I can remember it as if it was yesterday, the stinging smell of the acetic orcein (making Tjio's broad thumbs bright red also when squashing the cells) blending together with that of Turkish coffee made by Tjio.

from "Numbers, bands and recombination of human chromosomes:  Historical anecdotes from a Swedish student," by M. A. Hultén, in Cytogenetic and Genome Research 96:  14-19 (2002), pp. 15-16.

Need for a New Model for Epidemic Management?

Twentieth century model for epidemic management:

  • competition
  • battle
  • kill or be killed

Has this paradigm outlived its usefulness?


  • balance?
  • compromise?
  • collaboration?
  • domestication?....

Public Health and Private Lives

  • measure and analyze occurrence and distribution of diseases and other health-related conditions
  • look for shifts in disease patterns and search for their origin
  • isolate causal variables of disease to identify point of possible intervention

Can these tasks be accomplished with total objectivity?

Is total objectivity esssential?

What are the costs and benefits of objectivity in such an enterprise?

Do the needs of the many outweigh the needs of the few?

When and how should public and/or private agencies provide for common services:

  • Sanitation?
  • Water supply?
  • Medical care?
  • Subsidized food and shelter?
When and how should public and/or private agencies control individual behavior:
  • Quarantine?
  • Inoculation?
  • Food standards?
  • Building codes?
  • Behavioral restrictions?
When epidemic strikes, what is the appropriate balance between:
  • Individual vs. Community?
  • Private vs. Public?
  • Rights vs. Responsibilities?
  • Voluntary vs. Compulsory?

Some parting thoughts...

How do historic epidemics compare with those today?

How does the incidence of plague alter the social, political, economic, and moral fabric of affected communities?  How do individuals cope with the added stress in their daily lives?

What happens to accepted systems of explanation and belief in the face of such challenges?

Who will write the tales of the plagues of our time?  How might readers five hundred or a thousand years from now respond to them?


More Beasts for Worse Children
By Hilaire Belloc (1870-1953)

 The Microbe is so very small 
 You cannot make him out at all,
 But many sanguine people hope
 To see him down a microscope.
 His jointed tongue that lies beneath
 A hundred curious rows of teeth;
 His seven tufted tails with lots
 Of lovely pink and purple spots,
 On each of which a pattern stands,
 Composed of forty separate bands;
 His eyebrows of a tender green;
 All these have never yet been seen--
 But Scientists, who ought to know,
 Assure us they must be so....
 Oh! let us never, never doubt
 What nobody is sure about!

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