[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.

As long as you don't take seriously the hardship you are inflicting, you'll never be persuasive.

I do take it seriously, but there are three points I think should be made here.

First is that, yes, policy debates shouldn't appear one-sided. Policies of forcible quarantine, voluntary quarantine, tattooing, and so on do have costs, and those costs require a conversion factor to be compared to the benefits of the various policies, and people can differ on what they think those conversion factors should be.

Second is that I think that those conversion factors imply moral positions, and that it makes sense to condemn moral positions you disagree with strongly enough. If someone thinks that, to give an extreme example, we shouldn't imprison one person even if that prevents an epidemic that will murder a million people, I do not want them making public health decisions.

Third, the response to AIDS seems especially tragic to me because it put feelings above people, and is strong evidence against civilizational competence.

Voluntary quarantine is the obvious starting point. Pay or persuade sufferers to undergo quarantine.

Again, Typhoid Mary. She refused to believe that she was infecting others, or to seek work as anything besides a cook. The tool of 'pay her to do something other than cook' has similar local incentives as 'punish her for cooking', but it has very different global incentives. "Hey, all I need to do is contract typhus and then I can collect money for not working!" The local incentives aren't quite the same, either: "I think I get... one million dollars worth of satisfaction for cooking a meal!" It seems to me that one of the secondary uses of government is to prevent people from capturing the majority of the consumer surplus from trade, and you don't need to stretch epidemics too far to make them fit that mold.

I already gave cases on either side of the line; HIV and plague.

By 'clearly' I meant that everyone involved in the discussion agreed they were clear. From my perspective, HIV and plague look fairly difficult to distinguish in terms of impact, though I agree they're different in terms of transmission vector.

the burden of not-quarantine is that you don't get to have consequence-free casual sex (or share needles).

Recall that we are discussing about a third of a million preventable deaths, here. The primary burden for me is not that I don't have access to consequence-free casual sex, but the people I never met because they died early, and the friends whose futures are less certain and whose presents are less pleasant than they could be.

I worry that you're devaluing deaths due to this particular epidemic because a careful person could avoid catching the disease (unless, you know, they needed a blood transfusion at any point in their life). If all a disease does is increase the costs of being careful, then that's still reason enough to seek ways to fight the disease more effectively.

(And even if you personally are careful, you can't make your friends more careful; community health requires community hygiene.)

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 ... (read more)

0Lumifer12y

This is a good discussion, but let's not get silly. Typhoid Mary was a very unusual case in that she was a carrier but didn't have any symptoms. I really don't think there would have been a problem with people intentionally contracting typhus in order to get benefits and forgetting about the dying part.

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