drivers of health
health systems

What Causes AIDS Deaths? (Part 2)

By Austin Frakt

In the 1980s through the mid-1990s there was little the health system could do to address AIDS. Today there is a lot. Would we therefore attribute no deaths to AIDS in the 1980s and early 1990s to access to health care and some of them to that factor today?

On June 5, 1981, the Centers for Disease Control and Prevention reported a similar and inexplicable illness typical of immunosupressed patients in five gay men seen at three Los Angeles hospitals, two of whom had died. Unknown at the time, this was AIDS. The report speculated the illness and deaths were due to an “association between some aspect of a homosexual lifestyle or disease acquired through sexual contact.”

In other words, behavior. We might have said then, and many did, that behavioral factors (including unprotected sex, sharing of needles for intravenous drug use) caused AIDS deaths. (See this prior post on thinking about what causes AIDS deaths.)

Behavioral interventions were prominent — I remember some! Considerable efforts were made in the 1980s and 1990s to promote safe sex. Condoms were everywhere. A basket of them hung in my college dorm hallway in freshman year.

What few said early on was that AIDS deaths were due to the medical system. That started to change in the late 1980s. Activists and others noticed that the medical establishment wasn’t moving as quickly as it could to discover and make available HIV treatments. Years after AIDS was identified and had killed thousands, “the budget for AIDS research was a fraction of what the U.S. government spent on diseases that were far less threatening.”

A history of AIDS activism from NPR continues,

By early 1987, with the U.S. death toll topping 40,000 and worldwide HIV infections reaching 5 to 10 million, the threat was starting to feel apocalyptic. The gay community’s mounting frustration finally boiled over in an explosive show of anger.

Hundreds of gay men and their supporters took to New York City’s streets to vent their fury — first with a demonstration on Wall Street. Then a protest at city hall. Then an even bigger showdown on Wall Street.

After protests at the FDA in 1988 the agency redesigned clinical trial protocols providing accelerated access to experimental AIDS medications.

Today, with timely access to the right medications, AIDS deaths can be prevented. Therefore, it would be quite reasonable to attribute AIDS deaths to health system failures. What was once assumed to have only a behavioral cause now has predominantly a health system cause.

This isn’t just a story about AIDS. Until a few years ago, we didn’t have a way to cure hepatitis C. The deaths it causes are now attributable in part to access to health care (or lack thereof), whereas before behavioral factors were more likely to get the blame. The deaths from cancers that are now treatable we might have once just chalked up to genetics. Now the health system plays a role.

If we could reverse all of the negative health effects of smoking with health care, would we call smoking a bad health behavior? We can fix legs broken on the ski slopes with health care. Is downhill skiing a bad health behavior (at least relative to another form of exercise)?

And here’s the big question: If we change the degree to which the health system is responsible for health only when we identify successful treatments, why do we blame much of health on genetic, behavioral, or environmental factors not all of which can be changed with known interventions?

Just as not every disease is now curable by the health system, not every bit of DNA, behavior, or environmental factor that affects health can be changed … yet.