On May 6, 2016, Max Essex, the Lasker Professor of Health Sciences at Harvard and Chair of the Harvard AIDS Initiative, addressed the graduating class of 60 physicians at Marshall University’s Joan C. Edwards School of Medicine. The ceremony took place at the Keith-Albee Performing Arts Center in Huntington, West Virginia. Here are Essex’s remarks.
Special congratulations to all who are graduating. I’m honored to be invited to your celebration. You should feel gratified, proud, even exhilarated with what you have accomplished. You have chosen a wonderful profession. You will be greatly appreciated but also profoundly challenged by whatever track you choose. No area of knowledge is moving faster than medicine. Quite apart from the revolution in technology to access information, the pace of medical research assures that much of all you’ve learned will be obsolete in another 10 to 20 years when you are leaders in your profession.
I don’t quite know why your committee chose me as your commencement speaker, but I can only speak to you about something that reflects my own knowledge and experience. This would be infectious diseases, global health, and especially HIV/AIDS. Over the last year or two the public has been scared by ebola and zika. While important, these fears pale in comparison to what we saw with AIDS in the 1980s and 1990s.
Just a few decades ago, medical students were taught that infectious diseases would soon be a thing of the past. A vaccine eliminated smallpox and almost eliminated polio. But then came Lyme disease, Lassa, drug resistance, AIDS, and SARS, and infectious diseases are still a leading cause of death in much of the world.
The decade following discovery in 1981 was characterized by fear, stigma, and discrimination against those who acquired the infection. Patients and their friends and families had to protest and cause disruption to draw attention to their cause. The demonstrators disrupted medical meetings, held “die in’s” in Washington, and closed Wall Street.
One time in the late 1980s, I gave a lecture at the LBJ auditorium in Texas. It seemed to go well until the questions at the end. Two or three activists from the local chapter of Act Up shouted some hostile questions about why I was holding up drug research to cure the disease. I was confused and flustered as they were joined by other protesters. They were escorted out by security officers and, embarrassed, my host closed the session. As I left, a couple of the protestors approached me and said, “We want to apologize for what we said in there. We are actually very grateful to you for all you do. But the only way we can get the press and the politicians to listen is through protests and disruption; please don’t think this was directed at you.”
A couple of years later I was scheduled to host a large international AIDS conference in Boston. At the previous year’s conference in Italy, it was clear the protesters would close down our Boston meeting unless the US State Department ban against entry by HIV-positive citizens from other countries was lifted. In my final talk in Italy, which was supposed to say “Please come to Boston next year” and why, I spoke out with frustration about the harm done by both the discriminatory policies of my government and the protesters. It was the only time that a speech of mine was published verbatim in the Washington Post.
A few years after that, I was at a ceremony to receive an honorary degree at the University of Maryland. An official read the usual citation about my accomplishments in research. He then added something about how I also had the courage to speak up to my government about their discriminatory policies on people with HIV/AIDS. I was shocked, because sitting next to me, and next to receive his honorary degree, was the very same Secretary of Health and Human Services to whom I had voiced my protests.
Denialism also had its heyday with HIV/AIDS. Denialism of medical knowledge became evident around such things as smoking and lung cancer, and childhood vaccines and autism. But it also got major attention around HIV as the cause of AIDS, because the real etiology was too difficult for some to accept. We had no other examples of lethal infectious diseases where the clinical profile ranged from dementia to things like opportunistic TB or lymphoma, even though this all made sense when we understood that the real target of HIV was the immune system.
Apart from fear, denial, and discrimination, HIV/AIDS has been an important platform from which to appreciate the dimensions of medicine and the need for new knowledge. It used to be said that if you understand syphilis, you understand medicine. Now it is “If you understand HIV/AIDS, you understand medicine and public health.”
In the earliest days, AIDS was called GRID, the Gay Related Immunodeficiency Disease, or the 4H disease, because it seemed concentrated in homosexuals, heroin addicts, Haitians, and hemophiliacs. In early 1984, soon after the virus was discovered, we tested hemophiliacs from New England. Almost all were infected with HIV and almost all would go on to die of AIDS before drugs would become available. At about the same time, a new syndrome called slim disease or wasting disease was seen in east and central Africa. As AIDS expanded from thousands to millions, both many African leaders and President Reagan refused to acknowledge the existence of the disease. Fear, stigma, and denial extended to the highest levels, at least when it was politically convenient.
But the science progressed. Ironically, the virus causing AIDS was rapidly found because of knowledge in molecular biology developed by Nixon’s “War on Cancer.” That investment, which also gave us the biotechnology industry, showed that medical research is never wasted. By the late 1980s, the virus had been cloned and sequenced, and all its genes and gene products had been identified and characterized. Long before AIDS, we already had numerous good drugs against bacterial infections, yet many believed drugs would not work against viruses. But the new knowledge about HIV replication provided a pathway for strategic drug development. The first drug, AZT, was a by-product of cancer therapy research. New nucleoside and non-nucleoside reverse transcriptase inhibitors were designed.
With hundreds of thousands dying in the US and Europe, big pharma recognized the market opportunity – millions to be treated in the rich countries for the rest of their lives at whatever the cost. The reverse transcriptase inhibitors were soon followed by protease inhibitors to block virus assembly, fusion inhibitors to block virus release, and integrase inhibitors to prevent HIV from entering lymphocyte chromosomes. Now we have more than 40 drugs that target HIV. Careful use of these drugs allows patients to live essentially normal lives. In the late 1990s, an effective regimen cost $20,000 per year, projected for life. Now the best drug regimens are available in Africa for about $100 per year, and much of the cost is covered by the UN Global Fund, the Clinton Foundation, or US foreign aid through PEPFAR.
HIV/AIDS also taught us about the relationship between globalization and infectious diseases well before ebola and zika. Different HIVs undoubtedly entered the human population from apes and monkeys multiple times in sub-Saharan Africa. Green monkeys and mangabeys are common sources of bush meat. Until the late 1980s, chimps were, too, in places like eastern Congo or the Central African Republic. A large fraction of these primates have high levels of HIV-like viruses in their blood. When the carcass is cut up with sharp knives, the butcher is covered in infected blood, and accidental incisions could result in cross-species transmission. Such cross-species transmissions probably fizzled out in small populations 100 or 1,000 years ago. But then human migration, urbanization, population explosion, and changes in sexual practices may have allowed larger epidemics to begin, and the massive expansion of air travel brought in the rest of the world.
In the late 1990s, the President of Botswana invited me to evaluate the situation there on HIV/AIDS. The country had the highest rate of infection in the world, with more than one-third of adults infected and no drugs. One of 10 births was an HIV-infected baby. The funeral industry was the only thing that was doing well. In the year 2000, the UNAIDS agency estimated that 85% of all teenagers in Botswana would die of AIDS unless something changed. In 2001, my wife and I moved to Botswana on a sabbatical to see what we could do.
It seemed possible that antiretroviral drugs might make a huge difference in Africa. But about then, Andrew Natsios, a US government official who was head of USAID, made a highly publicized statement that Africans would probably not be able to take drugs for AIDS because they didn’t have watches and couldn’t tell time. When I heard that Merck and the Gates Foundation might test the concept of drug effectiveness in an African country, I helped bring them together with President Mogae of Botswana. Bill Gates soon visited. On World AIDS Day of 2001, the Botswana Harvard research and reference lab opened in Gaborone. At that time, the first of more than 300,000 Botswana citizens received drugs for AIDS. Patients’ lives were saved and the funeral industry fell on hard times. And soon new infections of infants were almost eliminated.
In late 2014, the UNAIDS set up a scorecard system to evaluate how well countries around the world are doing to treat AIDS patients and prevent new transmissions through treatment to render patients non-infectious to others. It is called 90-90-90, with goals that 90% of HIV-infected people in a country should know they are infected, 90% of them should be on therapy, and 90% of those on therapy should have complete suppression of HIV replication. Based on data from 2015, the country with the best score in the world is now Botswana, just above Switzerland, the UK, and Australia.
So let me summarize with just a few basic points:
First: As globalization expands, we must pay more attention to surveillance and control of infectious diseases in the developing world. To neglect doing so would be at our own peril.
Second: We should expect new and potentially devastating epidemics of infectious diseases in the next 10 to 20 years. They will probably kill many more people than ISIS and terrorism.
Third: We can conquer both these new epidemics and older infectious diseases with research, political will, and well-trained medical personnel—whom you are joining today.
And finally, once again, my warmest congratulations to the graduates.
Photos by Brian Patton, courtesy of Marshall University