Wednesday, April 29, 2009

AIDS: Unreal Confidence

My earlier post The Mirage of "The Cure" reminded me of a book by Abraham Verghese. In My Own Country: A Doctor’s Story of a Town and its People in the age of AIDS he described the mood of the medical community during the early years of AIDS. It was a time of "unreal confidence", and he vividly tells what it was like to be in the medical community when it seemed to know no obstacles.

Here are some passages:

I remember as an intern in 1981 reading a New England Journal of Medicine article with the curious title “Pneumocystis carinii Pneumonia and mucosal Candidiasis in Previously Healthy Homosexual Men—Evidence of a New Acquired Cellular Immunodeficiency.” It described the seminal AIDS cases in Los Angeles. Companion articles described cases in New York and San Francisco. Three things about these reports stayed in my mind: gay men, immune deficiency, and death.

The month the first papers on AIDS came out, the disease became a topic for late-night, idle discussion in the Mountain Home VA and Miracle Center cafeterias. ... We were seeing in our lifetime, so we told ourselves, yet another new disease. And surely, just like Legionnaire’s, Lyme disease, toxic shock—all new diseases—we felt this new disease, this mysterious immune deficiency, would soon be understood and conquered.

Although unexpected new diseases kept cropping up, this had not yet dented the profession’s confidence that they “would soon be understood and conquered.” Why was this so? Because of the enormous progress that had been made, because what was now routine was so amazing. We had progressed, if that’s the right word, to the point where we could treat the person as machinery, we could see the human body as a set of systems that we could control:

To say this was a time of unreal and unparalleled confidence, bordering on conceit, in the Western medical world is to understate things. Only cancer was truly feared, and even that was often curable. When the outcome of treatment was not good, it was because the host was aged, the protoplasm frail, or the patient had presented too late—never because medical science was impotent.

There seemed little that medicine could not do. As a lowly resident, I was inserting Swan-Ganz catheters into the vena cava and the right side of the heart. Meanwhile, the cardiologists were advancing fancier catheters through leg arteries and up the aorta, then using tiny balloons to open clogged coronary arteries or using lasers in Roto-Rooter fashion to ream out the grunge.

Surgeons, like Tom Starzl in Pittsburgh, had made kidney, liver, heart and heart-lung transplantation routine and they were embarking on twelve- to fourteen-hour “cluster operations” where liver, pancreas, duodenum and jejunum were removed en bloc from a donor and transplanted into a patient whose belly, previously riddled with cancer, had now been eviscerated, scooped clean in preparation for this organ bouquet.

Starzl was an icon for that period in medicine, the pre-AIDS days, the frontier days of every-other-night call. My fellow interns and I thought of ourselves as the vaqueros of the fluorescent corridors, riding the high of sleep deprivation, dressed day or night in surgical scrubs, banks of beepers on our belts, our tongues quick with the buzz words that reduced patients to syndromes—”rule out MI,” “impending DTs,” “multiorgan failure.” We strutted around with floppy tourniquets threaded through the buttonholes of our coats, our pockets cluttered with penlights, ECG calipers, stethoscopes, plastic shuffle cards with algorithms and recipes on them. The hemostats lost in the depths of our coat pockets were our multipurpose wrenches and found uses from roach clips to earwax dislodgers. Carried casually in sterile packaging in our top pockets were seven-gauge, seven-inch needles with twelve-inch trails of tubing. We were always ready—should we be first at a Code Blue—to slide needle under collarbone, into the great subclavian vein, and then to feed the serpent tubing down the vena cava in a cathartic ritual that established our mastery over the human body.

With this modern technology at our disposal, no medical problem would resist our efforts for long:

There seemed no reason to believe when AIDS arrived on the scene that we would not transfix it with our divining needles, lyse it with our potions, swallow it and digest it in the great vats of eighties technology.

As I write this, it is difficult to imagine that unreal time, 1983, in the history of AIDS. Not only did we not know what caused AIDS, there was no test to say who did and who did not have the mysterious disease.

The best that doctors across the country could do was to agree on a “definition” to ensure that everyone was talking about the same entity: if one was previously healthy and, for no obvious reason, developed an infection with an organism like pneumocystis or even developed Kaposi’s sarcoma, one had acquired immune deficiency syndrome. AIDS.

It seemed for a while that the confidence was justified, as real progress was indeed achieved:

Towards the end of my fellowship came the exciting news that Gallo and Montagnier (or Montagnier and Gallo depending on whom you believed—this too was part of the excitement: the personalities and the rivalries) had discovered that AIDS was caused by a virus: HIV.

A test to screen blood for HIV was rapidly-developed, and it was confirmed that all those who had AIDS carried the virus in their bodies.

... the mystery of causation had been solved.

Surely, the cure was just around the corner.

Over 25 years later, however, we are still searching ...

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