[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 don't know what this means. Could you explain?

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.

If you'd tried voluntary quarantine, and found it too hard (perhaps because of incentive problems), there would be something to discuss.

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 harder.)

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.

Agreed that the alternative wasn't immortality, but I don't see why you're not excited by the ability to adjust the risk of activities. I think consuming alcohol is inconsistent with my values; so I don't. But I don't write off alcoholics; I pity them, and if I could make alcoholism less destructive, I would. (If I expected a prohibition on alcohol to have positive expected value, I would support one; history is pretty clear that's not a good idea.)

Activities aren't risky or safe. There's a quantified risk associated with everything: consider driving. Driving is consistent with my values, and so I do it- but I wish it were cheaper, in terms of the risk of years lost, and I support government efforts to make driving safer to the degree that they seem effective. I almost never use boats myself, but I benefit from other people doing that- and I wish that were cheaper, in terms of risk, and I support government efforts to make shipping safer to the degree that they seem effective. And so on.

As far as I can tell, there has never been mass compulsory testing for diseases except for at the border.

Many US states required a Wassermann test before they would issue a marriage license, with the express purpose of protecting the innocent spouse (and any potential children) from contracting syphilis.

Actually considering the positions of both people is difficult but doable, and I think generally inconsistent with a rights-based view of morality.

Um, why do you think so? The "rights-based" view is not that "he has a right so no one can do anything". Instead, it is "he has a right, so he can decide whether to insist on it or not, or maybe to trade it for some benefit".

The core issue is who has the power, who decides. You are thinking of an impersonal entity above all whose freedom to choose the "optimal" solution... (read more)

-1Salemicus12y

No. The point is that people's rights are a key part of their position, and it's impossible to evaluate people's interests or "expected value" without considering their rights. That's not to say that you can never override people's rights, but it needs to take a lot, particularly if the violation is very serious (eg mass imprisonment of people who've committed no crime). Moreover, if you need my consent for your plan, that's a great way of making sure that you really are acting in my interests. There is no end to my suspicion of people who view breaching rights without consent as a minor hiccup in their plan, rather than a key reason to abandon it. [...] This is just rhetoric. An agile approach based on feedback and iteration is an equally good description. The failure of the "half-measure" should make you doubt the project a bit. It looks very much like you've got a hammer and are determined to wield it. [...] Hang on now. I think the pharmaceutical companies who came up with the various tests and anti-retrovirals etc did something worthwhile. I think the people who campaigned for condom use did something worthwhile. But I'm not excited about compulsory testing and mass imprisonment of the innocent. Once again, the question is: who should pay the costs of this risk adjustment? It looks to me very much like you want society as a whole (and HIV sufferers in particular) to subsidise your favourite recreational activity. You should pay. [...] Of course you would. And you'd place practically no weight on people's freedom to drink (or sell) what they want, and you'd place practically no weight on people's enjoyment of alcohol, but massive weight on the health drawbacks and drunk driving statistics and the occasional alcoholic. And then you'd add in the subconscious bias that you don't drink, so screw those guys (just as I do not believe for one second that you'd be in favour of a quarantine if it applied to you). Which is why people like you were gung-ho for prohib

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