International AIDS Society Newsletter, no. 16

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INTENATNAL

A Marvellous Book
AIDS Doctors: Voices from the Epidemic by Ronald Bayer and Gerald Oppenheimer.
Oxford University Press, New York, 2000, 304 pages.

This is a marvellous and inspirational book that
is surprising only in the sense that no-one has
done it before. It chronicles the history of the
HIV/AIDS epidemic in the United States
through the lives and experiences of approximately 75 doctors. Many of these individuals
became involved during the earliest days of the
epidemic and were among those who wrote the
first accounts in the literature of what we now
know to be HIV disease. Others only came into
the field later, but learned to share the emotions
and lessons of their predecessors. What marks
virtually all the physicians and caregivers who
are featured in this volume is a deep sense of
devotion to those patients who came under
their care, coupled with a desire to help the
cause of scientific advancement toward control
of the epidemic.
The book excels not only in describing this mix
of both passion and compassion on the part of
the doctors described but also in detailing the
wide heterogeneity of backgrounds from which
they came. Many were primary care physicians,
while others had been trained in a number of
different specialties and sub-disciplines, including clinical immunology, infectious diseases,
dermatology, and hematology, among others.
The book reminds us that AIDS had been
described as a medical condition, frequently
characterized by low CD4 counts, Kaposi's sarcoma, and susceptibility to opportunistic infections, long before we knew anything about HIV.
No wonder that so many of the pioneers in the
field came from disparate backgrounds. In
some cases, this later led to "turf battles" as
different groups of specialists tried to lay claim
to AIDS as belonging to their own discipline at
their respective institutions.
Of course, we understand today that HIV can
infect anyone. However, this was not clear in
the early days of the epidemic, and the book
does yeoman service in reminding us of the
fears and prejudices that characterized so many
members of the public, including physicians, in
the early 1980s, when it seemed that AIDS had

a special affinity for gay males. Looking back, it
now seems obvious that physicians who were
themselves gay must have been under extraordinary pressure from groups of activists to
come up with solutions in those early days.
This book reminds us of these harsh realities.
But it also successfully describes other aspects
of medical life, including the ambition of those
who were anxious to put their stamp on a new
disease as a stepping stone to a successful career.
The latter comment is not meant as a criticism
of either such individuals or of career ambitions in the domain of medical practice. It is a
fact that success in the context of medical career
advancement often necessitates long hours of
preparation of grant applications, research, and
clinical manuscripts, as well as patient care.
Little wonder that not everyone is willing to
devote themselves to the gruelling schedule that
this much work demands and that some choose
to drop out of the "academic system". Bayer
and Oppenheimer document these contrasting
attitudes and life choices in stark fashion.
In reading a book like this it is not uncommon
for a reviewer to already know many of the
individuals described, but it is always nice to
learn new things about such people as well as to
"get to know" others for the first time. Those
readers who do not know any of the players will
doubtless enjoy meeting them through these
pages. Of course, in any volume of this type,
there must also be omissions. Hopefully, noone
who considered themselves worthy of inclusion
will feel slighted because the authors had to
understandably limit the numbers of subjects
who could be covered. Another important
point, as acknowledged by the authors, is that
the list of those who have contributed to our
understanding of HIV disease is not limited to
physicians. Other types of caregivers, including
nurses, social workers, and counselors, among
others, are also deserving of recognition.
Perhaps, future volumes will do justice to the
contributions of these individuals as well as to

the chemists, immunologists, virologists and
others who set the stage for scientific advance.
Likewise, this book provides the reader with
glimpses of the AIDS epidemic exclusively
through the eyes of American clinicians. Again,
choices must be made and it is necessary to
start somewhere, but hopefully Bayer and
Oppenheimer, or other cataloguers of the epidemic, will someday compile the contributions
of caregivers from countries other that the US.
This should include documentation of the
pressures on caregivers in developing countries,
who must try to do their best, while knowing
that the vast majority of their patients are unlikely to ever have access to the antiretroviral
drugs that are now taken for granted in the
West.
If this book has any failing, it is probably the
manner in which it deals with the history of
antiretroviral therapy of HIV disease. It is probably misleading to quote select physicians as
stating that it is obvious, in retrospect, that
monotherapy could not have worked, and that
combination antiretroviral therapy would be
the only effective way to curb each of viral
replication, mutagenesis, and the development
of drug resistance. In reality, the development
of therapeutic approaches for treatment of HIV
disease could probably not have been speeded
up, even if it had been foreseen that monotherapy, or even bitherapy, would fail. This is
because the relative safety of AZT had to be
established before AZT could be given in combination with either 3TC or ddl. So too, the
safety and relative efficacy of the dual drug
regimens had to be known before trials of three
drugs in combination could go forward. However, this is a relatively minor flaw in a book that
provides valuable insights into the history of
the HIV/AIDS epidemic in the U.S. as well as
the lives, dedication, and sacrifices of so many
of the key physicians who helped set us on the
path of greater understanding and knowledge.
Mark A. Wainberg

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