Rick Keller, an assistant professor of medical history, explains the public health context in which HIV/AIDS was first reported by the Centers for Disease Control 25 years ago. Keller is team-teaching an interdisciplinary course on the global AIDS pandemic with Maria Lepowsky, a professor of anthropology. "In 1969, Surgeon General William Stewart told Congress that 'It is time to close the book on infectious diseases. The war against pestilence is over,'" Keller tells his students. "If any of you become surgeon general, never say anything like this. It's just bound to come back to haunt you."
Few infectious diseases in human history have posed more public health challenges than AIDS/HIV, a disease that has emerged in the past three decades to infect more than 40 million people worldwide.
But it is not only the medical challenges of AIDS that make the disease so vexing. Behavior, politics, economics, ideology and culture have all played a role in fostering "a perfect ecology" for the pandemic, one that will require more than just medicine to control.
A new course at the University of Wisconsin-Madison is exploring the AIDS pandemic from all of these varied points of view. "Global AIDS: Interdisciplinary Perspectives," has attracted undergraduate students from biology and medicine, political science, foreign language and history who are looking for a bigger-picture understanding of the disease.
"As an infectious disease, AIDS has the whole package -- it has sexuality, it has poverty, it has drug use," says Richard Keller, a history of medicine professor who is co-teaching the course with anthropologist Maria Lepowsky. "It's also a lentavirus that incubates for a long time before any symptoms appear. As far as risk factors are concerned, you couldn't find more dangers."
Societal perception also separates AIDS from other diseases, Keller says. "When we look at other infectious diseases -- malaria, polio, tuberculosis -- we tend to see them as a consequence of poverty or lack of healthcare access. Yet we tend to look at AIDS solely as a consequence of bad decision-making. We would argue that AIDS is really much more like other diseases, but we treat it much differently."
The 30 students in this course -- chosen from more than 100 applicants -- will explore the unique historical context for the emergence of AIDS. Keller notes that the disease developed in the early 1980s after a period of "tremendous public health complacency" in the United States. In 1969, then U.S. Surgeon General William Stewart declared to Congress that the war against pestilence was over and it "was time to close the book on infectious diseases."
The global eradication of smallpox - the world's No. 1 killer - was an enormous public health success, and other diseases such as TB and polio were relatively under control - at least in developed nations. Keller says infectious disease became a low priority with little funding support in the 1970s.
"Those other diseases didn't simply go away," Keller says. "They tended to be buried in at-risk populations who were the poorest and most marginalized."
Along with this false sense of health security came the sexual revolution, birth control and the view that sexuality was an expression of freedom. Antibiotics that controlled diseases such as gonorrhea and syphilis also created a disincentive for safe sex, he says.
On another social front in the 1970s was an explosion in drug use that paralleled the demise of American inner cities. Keller says that white flight, vanishing jobs and decayed infrastructure all contributed to a sense of hopelessness, and with it an exponential rise in addiction rates. The 1970s war on drugs, which criminalized possession of drug paraphernalia, pushed heroin users underground and gave rise to communal "shooting galleries" where needles were shared.
"The emergence of the disease in the 1980s kind of exploited this perfect ecology," Keller says. "You saw a classic environment for the spread of this disease."
Behavior then conspired with politics to further its spread. "AIDS has always been a political disease and it was absolutely anathema to talk about AIDS during the Reagan administration," Keller says. "Applications to study AIDS in the early 80s were buried. Surgeon General C. Everett Koop was barred from making public statements about AIDS until 1986."
Now, on a global scale, more political, economic and ethical challenges are at play in fighting the spread of the disease. Condom and needle distribution programs are losing ground in some regions of the world to abstinence-only beliefs. Evangelical faiths and radical forms of Islam are also increasing in some of the most economically desperate regions, further marginalizing AIDS education efforts.
Another interesting aspect of the disease is the development of treatments as a form of prevention. The anti-viral "cocktails" that control AIDS also make people far less infectious. But they are an extremely expensive, "First World phenomenon," Keller says, which offer little help in regions such as sub-Saharan Africa, where the disease is spreading the fastest.
The perplexing biology of the virus will also get attention in the course, as well as its exponential growth in Africa. Family medicine professor Cynthia Haq, one of many guest lecturers for the class, will talk about her extensive fieldwork in Uganda and other regions in AIDS/HIV prevention.
Students in the class were chosen on a competitive basis as instructors sought a broad mix of majors and interests. Katherine Guerra, for one, is an international studies major with both a personal and professional interest in the course. "The AIDS epidemic was a part of my life growing up in San Francisco," says Guerra, a junior. "Once I came to Wisconsin, I became interested in public health and international health. I'm also one of the coordinators of the local Student Global AIDS Campaign."
Students are required to make presentations to the class on selected topics, and Guerra says she will present research on the history of the disease in her home town, which had one of the nation's highest AIDS incidence rates in the 1980s.
Abby Neely, a doctoral student in history and geography, is also deeply immersed professionally in AIDS and global health issues. She spent eight months last year in Namibia, where she worked on connections between environmental degradation and disease.
The Boston native has degrees from Princeton and Oxford, but came to Madison because of its strong program in environmental health. She says the class will give her a better historical and social context for her future work. "I think AIDS is a human rights issue because it's about access to medical care and information," she says. "It is hitting countries with no money and high population densities and little health care. It's a scary proposition."
What does the future hold for the AIDS pandemic? The students in this class will face a grim outlook.
Keller says the best-case scenario -- vaccine development and widespread distribution -- is highly unlikely, primarily due to financial implications and the slippery nature of the virus. A more moderate scenario would be making cheaper anti-viral drugs more widely available to the developing world, but even that prospect faces hurdles such as global patent laws that restrict the development of cheaper generics.
The worst-case scenario? "The status quo," Keller says. The next Africa , in terms of infection rates, could be India and China. "Both countries have grossly underestimated rates of infection, both have an increasing sex trade, and both have done nothing to stop the spread of AIDS. These are recipes for disaster."
This course was developed by UW-Madison International Studies as a "capstone" offering for undergraduate seniors. The team-taught seminar is meant to explore globalization through the lens of a single major topic. Each year, a different topic will be explored to help define how the concept of "globalization" is manifesting itself in culture and politics. Other future topics are likely to include terrorism and environmental issues, such as global warming, that recognize no boundaries.