The NEW ENGLA ND JOURNAL of MEDICINE

Perspective june 6, 2013

How AIDS Invented Global Health

Allan M. Brandt, Ph.D.
Related article, p. 2210

O ver the past half-century, historians have used

episodes of epidemic disease to investigate
scientific, social, and cultural change. Underlying
health,” replacing them with in-
novative global approaches to dis-
ease. Indeed, the HIV epidemic
and the responses it generated
this approach is the recognition that disease, and have been crucial forces in “in-
venting” the new “global health.”
especially responses to epidemics, 2218), combating the epidemic This epidemic disrupted the
offers fundamental insights into remains a test of our expanding traditional boundaries between
scientific and medical practices, as knowledge and vigilance. public health and clinical medi-
well as social and cultural values. Nonetheless, the progress made cine, especially the divide be-
As historian Charles Rosenberg in addressing this pandemic and tween disease prevention and
wrote, “disease necessarily reflects its effects on science, medicine, treatment. In the 1980s, before
and lays bare every aspect of the and public health have been far- the advent of antiretroviral thera-
culture in which it occurs.”1 reaching (see timeline). The chang- pies, public health officials fo-
Many historians would consid- es wrought by HIV have not only cused on controlling social and
er it premature to write the his- affected the course of the epi- behavioral risk factors; preven-
tory of the HIV epidemic. After demic: they have had powerful tion was seen as the only hope.
all, more than 34 million people effects on research and science, But new treatments have eroded
are currently infected with HIV. clinical practices, and broader this distinction and the histori-
Even today, with long-standing policy. AIDS has reshaped conven- cal divide between public health
public health campaigns and tional wisdoms in public health, and clinical care.2 Clinical trials
highly active antiretroviral ther- research practice, cultural atti- have shown that early treatment
apy (HAART), HIV remains a tudes, and social behaviors. Most benefits infected patients not
major contributor to the burden notably, the AIDS epidemic has only by dramatically extending
of disease in many countries. As provided the foundation for a life expectancy, but by signifi-
Piot and Quinn indicate in this revolution that upended tradition- cantly reducing the risk of trans-
issue of the Journal (pages 2210– al approaches to “international mission to their uninfected sexu-

n engl j med 368;23  nejm.org  june 6, 2013 2149

The New England Journal of Medicine
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 2150
2000
1987 13th International AIDS Conference, held in
FDA approves AZT, first antiretroviral drug for AIDS; Durban, South Africa, focuses on the global
accelerates approval of Treatment Investigational New pandemic, especially in the developing world
1985 Drugs 2009
FDA approves first licensed Durban Declaration, signed by 5000 President Barack Obama
PERSPE C T I V E

test for HIV
First International AIDS
Conference held in Atlanta
Project Inform founded to
promote faster government
approval of HIV drugs
1983
People With AIDS Network
establishes the Denver
Principles to encourage
empowerment and fight
discrimination
AIDS Coalition to Unleash Power (ACT UP) founded prominent clinicians and investigators, establishes the Global
attests to overwhelming evidence that HIV Health Initiative to
United Nations holds first debate on disease in causes AIDS, counteracting AIDS “denialism”
General Assembly develop a comprehensive
UNAIDS, WHO, and pharmaceutical approach to global health
Global Program on AIDS created by World Health companies establish initiative to negotiate in low- and middle-
Organization (WHO) reduced prices for HIV drugs in developing income nations
countries Obama administration
UN Security Council declares AIDS a lifts HIV travel and
1990 immigration ban
1995 security threat
Congress passes Ryan
White Act to fund Saquinavir, first protease
treatment and inhibitor approved by 2008
community-based care; FDA, initiates era of highly Congress reauthorizes
first-year allocation is active antiretroviral PEPFAR for 5 more 2013
$220.5 million therapy (HAART) years, allocating up to Indian Supreme Court
$48 billion rejects Novartis claim of
Americans with

n
patent violation for
Disabilities Act passed to 2004 Gleevec, maintaining the

DE
protect persons with

The
ME
1981 The leaders of the Group of Eight (G8) right of manufacturers

Title

Copyright © 2013Artist
engl
disabilities (including countries establish the Global HIV

Fig # j
Author
First clinical reports of what

Downloaded from nejm.org on November

there to produce generics

Pub Date
will later be determined to be AIDS) from Vaccine Enterprise, a consortium of for essential medicines
discrimination government and private-sector groups

Draft 3

med
acquired immunodeficiency
syndrome (AIDS) to accelerate research

Fields
New Global
15,Malina
Williams
6/6/2013
Massachusetts
England
1980 1985 1990 1995 2000 2005 2010 2015

COLOR FIGURE

Brandt_p1305297

How AIDS invented

1982

5/16/2013
Gay Men’s Health Crisis 1996 2005
(first community-based AIDS UNAIDS established by UN General Assembly reviews
service provider) established the United Nations, targets set in 2001 in special
in New York City combining experts session on HIV–AIDS
from six agencies

HealthJournal of Medicine
1991 WHO, UNAIDS, U.S.

1 368;23 nejm.org june 6,

International Council of AIDS government, and Global Fund
Service Organizations established jointly announce results of 2011

2013
1984 2001 HIV Prevention and
as network for nongovernmental World Trade Organization programs to reduce costs of
Scientists in France and and community-based essential drugs in developing Trials Network (HPTN)
the United States announces Doha Declaration, 052 shows that early
organizations to facilitate production and countries
identify causative agent, treatment of HIV-infected
later named human purchase of generic drugs for persons greatly reduces

Medical Society. All rights reserved.

immunodeficiency virus health crises such as AIDS transmission to
(HIV) 1994 uninfected sexual
AIDS Clinical Trial Group 2003
President George W. Bush partners
Study 076 shows 70%
reduction in perinatal HIV announces President’s
1986 2002 Emergency Plan for AIDS
transmission among Global Fund to Fight AIDS,
First clinical trials of Relief (PEPFAR), a $15
women who take AZT Tuberculosis, and Malaria
azidothymidine (AZT) billion program to fight
during pregnancy established AIDS in poor countries

2022. For personal use only. No other uses without permission.

William H. Gates HIV is leading cause of death
1988 Foundation is created
WHO declares first worldwide among people 15
(renamed Bill and Melinda to 59 years of age
World AIDS Day Gates Foundation in 1999)
How AIDS Invented Global Health
PERSPECTIVE
al partners.3 Essential medicines
benefit both patients and popu-
lations, providing a critical tool
for reducing fundamental health
disparities. This insight has en-
couraged the integration of ap-
proaches to prevention and treat-
ment, in addition to behavioral
change and adherence.
The rapid development of ef-
fective antiretroviral treatments,
in turn, could not have occurred
without new forms of disease
advocacy and activism. Previous
disease activism, for example,
had established important cam-
paigns supporting tuberculosis
control, cancer research, and the
rights of patients with mental ill-
ness. But AIDS activists explicitly
crossed a vast chasm of exper-
tise. They went to Food and
Drug Administration meetings
and events steeped in the often-
arcane science of HIV, prepared
to offer concrete proposals to
speed research, reformulate trials,
and accelerate regulatory pro-
cesses. This approach went well
beyond the traditional bioethical
formulations of autonomy and
consent. As many clinicians and
scientists acknowledged, AIDS
activists, including many people
with AIDS, served as collabora-
tors and colleagues rather than
constituents and subjects, chang-
ing the trajectory of research and
treatment.4 These new models of
disease activism, enshrined in the
Denver Principles (1983), which
demanded involvement “at every
level of decision-making,” have
spurred new strategies among
many activists focused on other
diseases. By the early 2000s,
AIDS activists had forged impor-
tant transnational alliances and
activities, establishing a critical
aspect of the “new” global health.
Furthermore, HIV triggered
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important new commitments in
the funding of health care, par-
ticularly in developing countries.
With the advent of HAART and
widening recognition of HIV’s po-
tential effect on the fragile prog-
ress of development in resource-
poor settings, HIV spurred
substantial increases in funding
from sources such as the World
Bank. The growing concern in
the United Nations and else-
where that the epidemic posed
an important risk to global “se-
curity” elicited new funding from
donor countries, ultimately re-
sulting in the establishment of
the Global Fund to Fight AIDS,
Tuberculosis, and Malaria. In
2003, it was joined by the U.S.
President’s Emergency Plan for
AIDS Relief (PEPFAR), which,
with bipartisan support, initially
pledged $15 billion over 5 years.
Since PEPFAR’s inception, Con-
gress has allocated more than
$46 billion for treatment, infra-
structure, and partnerships that
have contributed to a 25% reduc-
tion in new infections in sub-
Saharan Africa.
HIV has also attracted re-
markable levels of private philan-
thropy, most notably from the
Bill and Melinda Gates Founda-
tion. HIV funding led to new
public–private partnerships that
have become a model for fund-
ing of scientific investigation,
global health initiatives, and
building of crucial health care
delivery infrastructure in devel-
oping countries. These funding
programs have fomented conten-
tious debates about priorities, ef-
ficiency, allocation processes, and
broader strategies for preventing
and treating many diseases, es-
pecially in poorer countries. None-
theless, they offered new ap-
proaches to identifying critical
How AIDS Invented Global Health
resources and evaluating their ef-
fect on the burden of disease.
The success of future efforts will
depend on maintaining and ex-
panding essential funding dur-
ing a period of global economic
recession, as well as new strate-
gies for evaluating the efficacy of
varied interventions.
AIDS also spurred another re-
lated debate that continues to
roil global health — about the
cost of essential medicines. Ac-
cessibility of effective and pre-
ventive treatments has relied on
the availability of reduced-cost
drugs and their generic equiva-
lents. A recent decision by the
Indian Supreme Court upheld
India’s right to produce inexpen-
sive generics, despite the multi-
national pharmaceutical industry’s
claims for stronger recognition
of patents.
Another central aspect of the
new activism was an insistence
that the AIDS epidemic demanded
the recognition of basic human
rights. Early on, lawyers, bioethi-
cists, and policymakers debated
the conditions under which tra-
ditional civil liberties could be
abrogated to protect the public
from the threat of infection.
Such formulations reflected tradi-
tional approaches to public health
and the “police powers” of the
state, including mandatory test-
ing, isolation, detention, and
quarantine. Given the stigma at-
tached to HIV infection at the
time, as well as ungrounded
fears of casual transmission, af-
fected people often suffered the
double jeopardy of disease and
discrimination. As a result, Jona-
than Mann, the first director of
the World Health Organization’s
Global Program on AIDS, ex-
plained, “To the extent that we
exclude AIDS infected persons
2151
PERSPE C T I V E
from society, we endanger society,
while to the extent that we main-
tain AIDS infected persons with-
in society, we protect society. This
is the message of realism and of
tolerance.”5 Mann argued that
HIV could never be successfully
addressed if impositions on hu-
man rights led people to hide
their infections rather than seek
testing and treatment. Only pol-
icy approaches that recognized
and protected human rights (in-
cluding the rights to treatment
and care, gender equality, and
education) would permit success-
ful clinical and population-based
interventions.
These complementary innova-
tions are at the core of what we
now call “global health” —
which has demonstrated its ca-
pacity to be far more integrative
than traditional notions of inter-
national health. It draws togeth-
er scientists, clinicians, public
health officials, researchers, and
patients, while relying on new
sources of funding, expertise,
and advocacy. This new formula-
tion is distinct, first of all, in
that it recognizes the essential
War and Sexual Violence — Mental Health Care for Survivors
Charlotte Watts, Ph.D., Mazeda Hossain, M.Sc., and Cathy Zimmerman, Ph.D.
T here has been growing inter-
national concern about rape
in fragile or volatile countries,
especially those involved in armed
conflicts; indeed, this concern
has inspired the United Nations
Security Council to issue nine
sexual-violence–related resolu-
tions since 2000.1 Sexual violence
is a human-rights abuse that of-
ten results in severe health con-
sequences, including acute and
2152
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Copyright © 2013 Massachusetts Medical Society. All rights reserved.
supranational character of prob-
lems of disease and their amelio-
ration and the fact that no indi-
vidual country can adequately
address diseases in the face of
the movement of people, trade,
microbes, and risks. Second, it
focuses on deeper knowledge of
the burden of disease to identify
key health disparities and devel-
op strategies for their reduction.
Third, it recognizes that people
affected by disease have a crucial
role in the discovery and advoca-
cy of new modes of treatment
and prevention and their equita-
ble access. Finally, it is based on
ethical and moral values that rec-
ognize that equity and rights are
central to the larger goals of pre-
venting and treating diseases
worldwide.
For more than the past decade,
major academic medical centers,
schools of public health, and
universities have created global
health programs and related in-
stitutes for multidisciplinary re-
search and education. Thus, the
institutionalization of this for-
mulation is not only affecting
services worldwide, but also
longer-term psychological prob-
lems, such as depression, anxi-
ety, and post-traumatic stress
disorder (PTSD). In addition to
the short- and long-term effects
on survivors and their families,
the aftermath of widespread sex-
ual violence can affect the com-
munity at large. A pressing chal-
lenge is therefore to determine
how to help survivors and com-
munities overcome the psycho-
n engl j med 368;23  nejm.org  june 6, 2013
The New England Journal of Medicine
How AIDS Invented Global Health
changing the training of physi-
cians, other health professionals,
and students of public health.
When the history of the HIV epi-
demic is eventually written, it
will be important to recognize
that without this epidemic there
would be no global health move-
ment as we know it today.
Disclosure forms provided by the author
are available with the full text of this arti-
cle at NEJM.org.
From the Department of the History of Sci-
ence, Harvard University, Cambridge, MA,
and the Department of Global Health and
Social Medicine, Harvard Medical School,
Boston.
1. Rosenberg CE. Disease and social order
in America: perceptions and expressions.
Milbank Q 1986;64:Suppl 1:55. abstract.
2. Brandt AM, Gardner M. Antagonism and
accommodation: interpreting the relation-
ship between public health and medicine in
the United States during the 20th century.
Am J Public Health 2000;90:707-15.
3. Cohen MS, Chen YQ, McCauley M, et al.
Prevention of HIV-1 infection with early anti-
retroviral therapy. N Engl J Med 2011;365:
493-505.
4. Killen J, Harrington M, Fauci AS. MSM,
AIDS research activism, and HAART. Lancet
2012;380:314-6.
5. Mann JM. Statement at an informal brief-
ing on AIDS to the 42nd session of the Unit-
ed Nations. J R Stat Soc [A] 1988;151:131-6.
DOI: 10.1056/NEJMp1305297
Copyright © 2013 Massachusetts Medical Society.
Related article, p. 2182
logical effects of large-scale ex-
posure to sexual violence and the
other traumatic events that com-
monly occur in war-torn states.
Postconflict reconstruction ef-
forts have traditionally focused
on security, health, physical in-
frastructure, and economic de-
velopment; they have been less
well-equipped to respond to or
prevent sexual and other forms of
violence against women. Although