[Link] Forty Days

GLaDOS

A post from Gregory Cochran's and Henry Harpending's excellent blog West Hunter.

One of the many interesting aspects of how the US dealt with the AIDS epidemic is what we didn’t do – in particular, quarantine. Probably you need a decent test before quarantine is practical, but we had ELISA by 1985 and a better Western Blot test by 1987.

There was popular support for a quarantine.

But the public health experts generally opined that such a quarantine would not work.

Of course, they were wrong. Cuba institute a rigorous quarantine. They mandated antiviral treatment for pregnant women and mandated C-sections for those that were HIV-positive. People positive for any venereal disease were tested for HIV as well. HIV-infected people must provide the names of all sexual partners for the past sic months.

Compulsory quarantining was relaxed in 1994, but all those testing positive have to go to a sanatorium for 8 weeks of thorough education on the disease. People who leave after 8 weeks and engage in unsafe sex undergo permanent quarantine.

Cuba did pretty well: the per-capita death toll was 35 times lower than in the US.

Cuba had some advantages: the epidemic hit them at least five years later than it did the US (first observed Cuban case in 1986, first noticed cases in the US in 1981). That meant they were readier when they encountered the virus. You’d think that because of the epidemic’s late start in Cuba, there would have been a shorter interval without the effective protease inhibitors (which arrived in 1995 in the US) – but they don’t seem to have arrived in Cuba until 2001, so the interval was about the same.

If we had adopted the same strategy as Cuba, it would not have been as effective, largely because of that time lag. However, it surely would have prevented at least half of the ~600,000 AIDS deaths in the US. Probably well over half.

I still see people stating that of course quarantine would not have worked: fairly often from dimwitted people with a Masters in Public Health.

My favorite comment was from a libertarian friend who said that although quarantine certainly would have worked, better to sacrifice a few hundred thousand than validate the idea that the Feds can sometimes tell you what to do with good effect.

The commenter Ron Pavellas adds:

I was working as the CEO of a large hospital in California during the 1980s (I have MPH as my degree, by the way). I was outraged when the Public Health officials decided to not treat the HI-Virus as an STD for the purposes of case-finding, as is routinely and effectively done with syphilis, gonorrhea, etc. In other words, they decided to NOT perform classic epidemiology, thus sullying the whole field of Public Health. It was not politically correct to potentially ‘out’ individuals engaging in the kind of behavior which spreads the disease. No one has recently been concerned with the potential ‘outing’ of those who contract other STDs, due in large part to the confidential methods used and maintained over many decades. (Remember the Wassermann Test that was required before you got married?) As is pointed out in this article, lives were needlessly lost and untold suffering needlessly ensued.

The Wasserman Test.

A post from Gregory Cochran's and Henry Harpending's excellent blog West Hunter.

One of the many interesting aspects of how the US dealt with the AIDS epidemic is what we didn’t do – in particular, quarantine. Probably you need a decent test before quarantine is practical, but we had ELISA by 1985 and a better Western Blot test by 1987.

There was popular support for a quarantine.

But the public health experts generally opined that such a quarantine would not work.

Of course, they were wrong. Cuba institute a rigorous quarantine. They mandated antiviral treatment for pregnant women and mandated C-sections for those that were HIV-positive. People positive for any venereal disease were tested for HIV as well. HIV-infected people must provide the names of all sexual partners for the past sic months.

Compulsory quarantining was relaxed in 1994, but all those testing positive have to go to a sanatorium for 8 weeks of thorough education on the disease. People who leave after 8 weeks and engage in unsafe sex undergo permanent quarantine.

Cuba did pretty well: the per-capita death toll was 35 times lower than in the US.

Cuba had some advantages: the epidemic hit them at least five years later than it did the US (first observed Cuban case in 1986, first noticed cases in the US in 1981). That meant they were readier when they encountered the virus. You’d think that because of the epidemic’s late start in Cuba, there would have been a shorter interval without the effective protease inhibitors (which arrived in 1995 in the US) – but they don’t seem to have arrived in Cuba until 2001, so the interval was about the same.

If we had adopted the same strategy as Cuba, it would not have been as effective, largely because of that time lag. However, it surely would have prevented at least half of the ~600,000 AIDS deaths in the US. Probably well over half.

I still see people stating that of course quarantine would not have worked: fairly often from dimwitted people with a Masters in Public Health.

My favorite comment was from a libertarian friend who said that although quarantine certainly would have worked, better to sacrifice a few hundred thousand than validate the idea that the Feds can sometimes tell you what to do with good effect.

The commenter Ron Pavellas adds:

I was working as the CEO of a large hospital in California during the 1980s (I have MPH as my degree, by the way). I was outraged when the Public Health officials decided to not treat the HI-Virus as an STD for the purposes of case-finding, as is routinely and effectively done with syphilis, gonorrhea, etc. In other words, they decided to NOT perform classic epidemiology, thus sullying the whole field of Public Health. It was not politically correct to potentially ‘out’ individuals engaging in the kind of behavior which spreads the disease. No one has recently been concerned with the potential ‘outing’ of those who contract other STDs, due in large part to the confidential methods used and maintained over many decades. (Remember the Wassermann Test that was required before you got married?) As is pointed out in this article, lives were needlessly lost and untold suffering needlessly ensued.

The Wasserman Test.

I think that those conversion factors imply moral positions, and that it makes sense to condemn moral positions you disagree with strongly enough... I do not want [people I disagree with] making public health decisions.

Agreed 100%. There has been an undertone in my posts of moral condemnation; and it's intentional. I do not want someone like Cochran making decisions about individual liberty.

[T]he response to AIDS seems especially tragic to me because it put feelings above people, and is strong evidence against civilizational competence.

I don't know what this means. Could you explain? It seems to me that the AIDS response put people's liberty before people's lifespan. This is not an uncontroversial choice, but it doesn't seem an obviously wrong one; both are about people, neither about 'feelings,' - except to the extent that 'feelings' reside within people. As for civilizational competence, it strikes me that civilisation is rolling along just fine; if anything, the AIDS epidemic appears to have played a major role in the major shift from homosexuals whining about "heteronormativity" to campaigning for gay marriage.

Incentives.

Of course there would be problems with voluntary quarantine. If you'd tried voluntary quarantine, and found it too hard (perhaps because of incentive problems), there would be something to discuss. But if you don't try the first step, and immediately go for the nuclear option, I find it hard to take you seriously. Do you really think there would be no perverse incentives, regulatory overreach, etc, in a massive government programme of compulsory quarantine and HIV tests?

Recall that we are discussing about a third of a million preventable deaths, here... I worry that you're devaluing deaths due to this particular epidemic because a careful person could avoid catching the disease

No. But perhaps we have different models of causation.

Basically, I see someone who dies of AIDS as basically the same as someone who dies of scuba-diving. They did something risky (but presumably fun), they had bad luck, they died. So it goes. It's sad, but the alternative wasn't immortality. To the extent their deaths were "preventable," it was all in their own power, and they chose not to. They caused their own deaths.

The subtext to your position appears to be that the government has some kind of "heroic duty" to save lives. Sharing needles and having casual unprotected sex are dangerous and foolish, but people are going to do them regardless, and so it's the government's duty to make those activities as safe as possible. The government caused their deaths by not doing more to prevent them.

I'm not going to get into a debate about "heroic duty," but I would say this; you are calling for extraordinary measures. As far as I can tell, there has never been mass compulsory testing for diseases except for at the border. You are, to continue the analogy, trying to make a huge, costly, unprecedented and coercive effort to make scuba-diving safer, at particularly great cost to people in the vicinity of the scuba-divers, as well as liberty generally. Yet you are unable to justify why the safety-conscious scuba-divers shouldn't pay those costs themselves, and you aren't willing to try voluntary measures as a first step. It seems clear that the primary cost of making scuba-diving safer should fall on the people who want to go scuba-diving, and if they aren't willing to pay that cost, then I'll be damned if I'll subsidise them, and I'll be doubly damned if I'll help them victimize others.

Sharing needles and having casual unprotected sex are dangerous and foolish

Casual unprotected sex wasn't the only sexual risk-- the others were rape and having unprotected sex with an untrustworthy long term partner.

4Vaniver12y

Sure. I think people's first instinct whenever they encounter a policy question is to ask who they identify with. Is it the carrier of AIDS whose freedom or bodily autonomy would be violated by a quarantine or a tattoo, or is it the person at risk for AIDS? Actually considering the positions of both people is difficult but doable, and I think generally inconsistent with a rights-based view of morality. If we just say "liberty first!" then we make crazy trades where we give up many years of life for a bit of liberty; if we just say "lives first!" then we make crazy trades where we give up significant amounts of life satisfaction for a few lives; if we say "this is the tradeoff between life and liberty that we think it reasonable" then we have an actually quantitative discussion (which is less likely to be crazy). It seems to me (with the disclaimer that I'm not a historian) that most LGBT activists decided they identified with the people who had HIV, and so they advocated voluntary testing, and voluntary disclosure, and against policies that might possibly 'out' people, because they felt it more important to maintain the option to keep sex lives private than to prevent the spread of the disease. It's also claimed that Reagan mostly brushed the issue off because he identified with neither the carriers nor those at risk (until famous actors that he knew started dying), but, again, I'm not a historian. [...] The time to close the stable door is before the horse escapes. As mentioned earlier, I think the cost/benefit has shifted on HIV to the point where quarantine isn't a good idea anymore (but compulsory testing and tattooing might still make sense). Trying half measures and then doubling down if they fail doesn't seem like a strong strategy relative to starting with the full approach in the presence of exponentially growing risks. (This is especially true if the failure of the half measure leads to discrediting the project, rather than to support for trying it hard

7Lumifer12y

Let me dial that up to 11 X-) So, the suggested remedy is to forcibly separate the society into the clean and the unclean, and to brand the unclean with an indelible mark. What could possibly go wrong? And let's talk practicalities. By the time AIDS was recognized as a serious threat and there were reliable tests for HIV status, how many HIV-positive people were there in the US already? Quarantines work well when you need to quarantine a few or a few dozens of people, not well-dispersed thousands and tens of thousands. How would compulsory testing work given that people know that failing the test leads to being branded unclean? Troops isolating city block by city block and dragging all inhabitants to a field testing station? How about costs of that?

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