01 December 2006

Why Give Special Attention To AIDS?

Today is World AIDS Day.

The Last Big Deadly Natural Threat

What makes a focus on this disease appropriate?

AIDS is the last big deadly natural threat that nature poses to humans in the United States.

AIDS is the only major infectious disease, in the United States at least, that routinely kills adults in their prime. The other infectious diseases that are deadly, flu and pnemonia, are less common causes of death for people 25-54, and are only a slightly more common cause of death among those age 15-24 (keep in mind that infection with HIV and death from AIDS are usually far removed in time, these represent early childhood infections for the most part).

AIDS kills thousands of Americans each year. In 2004, AIDS killed 15,798 people in the United States, all but 61 of whom were adults or adolescents. Only about 2% of those killed by AIDS were diagnosed with the disease before age 13 or after age 65. A third of those diagnosed with AIDS are in the 30s when diagnosed.

In 2000, AIDS ranked as a leading cause of death in the following age ranges is as follows:
5-14 #13
15-24 #10
25-34 #6
35-44 #5
45-54 #8
54-64 #14

Trauma (i.e. accidents, homicide and suicide) is the leading cause of death for persons age 1-44. AIDS rank among non-traumatic causes of death is as follows:
5-14 #10 (influenza and pnemonia killed 87, AIDS killed 46)
15-24 #7 (influenza and pnemonia killed 189, AIDS killed 179)
25-34 #2 (influenza and pnemonia killed 364, AIDS killed 2,437)
35-44 #3 (influenza and pnemonia killed 1,068, AIDS killed 5,919)
45-54 #6 (influenza and pnemonia killed 1,774, AIDS killed 4,142)
54-64 #12 (influenza and pnemonia killed 2,879, AIDS killed 1,239)

For African Americans, AIDS rank among non-traumatic causes of death is as follows:
5-14 #6 (influenza and pnemonia killed 11, AIDS killed 23)
15-24 #3 (influenza and pnemonia killed 44, AIDS killed 125)
25-34 #1 (influenza and pnemonia killed 93, AIDS killed 1,432)
35-44 #3 (influenza and pnemonia killed 257, AIDS killed 3,080)
45-54 #3 (influenza and pnemonia killed 425, AIDS killed 2,257)
55-64 #8 (influenza and pnemonia killed 538, AIDS killed 636)

There are other deadly communicable diseases, such as bubonic plague, West Nile Virus, pneumonia, TB and flu. But, they predominantly kill the very young, the very old, thoses will immune systems weakened by AIDS or other diseases, and people who don't seek medical treatment. For the old and those with weakened immune systems, it is more fair to calls these diseases complications of something else, be it another disease or simply old age, than a death attributable to the disease itself. Vaccines, anti-biotics, mosquito control, and good sanitation have collectively wiped out most other deadly infectious diseases, or caused them to no longer be deadly to adults in their prime.

There are other incurable deadly communicable diseases that kill adults in their prime in the world, but they are largely confined to the tropics and subtropics. Whether or not it is fair, they are off the radar screen of most of the industrialized world in Europe, Canada, the United States and Japan.

At least in the United States, we've pretty much eliminated all other external threats to non-elderly adults in the United States that aren't of our own devising.

The number of healthy adults killed each year by animals, either predators or venomous, is about a couple hundred a year.

There are only two kinds of deadly poisonous spiders in the United States (the black widow and brown recluse), neither of which is usually deadly except to small children. Scorpions also usually only kill small children. There is only one deadly lizard in the United States (the Gila Monster which is confined to the deserts of the Southwest) and there have been no recent deaths caused by it. The most deadly poisonous snaks in the United States are the copperhead (who bies is very seldom fatal), the cotton mouth water moccasin which has low mortality (under 2%), the rattlesnake (with low mortality but frequent amputations made necessary). These snakes are only found in some parts of the U.S. Poisonous snakes, spiders, and lizards killed only 10 people in 2003. Allegeric reactions to bea and wasp stings (and in a few rare cases, massive swarm attacks) killed 66 people in 2003. Other poisonous plants and animals killed 18 people.

The big predator species like mountain lions, grizzly bears and wolves, are almost all rare and endangered. Only a few people die from sharks each year. Non-poisonous animal attacks killed 122 people in 2003, 32 of which were dogs, mostly killing young children.

The only poisonous reptile in Europe is the European viper, whose bite has low mortality. The only poisonous spider of any danger to humans in Europe is the hobo spider (and its lethality is marginal at best). Big predator species are even more rare in Europe, which has fewer truly wild places than the United States. Much of Europe has none of the warm waters which are home to most potentially deadly sea animals than the United States.

Natural disasters and lightning strikes are relatively minor killers in the bigger scheme of things, averaging a couple of hundred deaths each year, and we know what to do to deal with most of them, even if we don't always do it. On occassion a major hurricane or flood kills a large number of people, as it did when Katrina struck. But, these major, deadly natural disasters are usually always proceeded with ample warning. Avalanches rarely kill those who aren't actively seeking out risky situations. While several thousands of people die each year in fires, the overwhelming majority of those fires (about 98%) are indoor fires or controlled fires with human origins, not wildfires outdoors.

There are still adults who die in the United States of exposure to the elements. In 2003, 620 died from exposure to cold in 2003, many of whom were vagrants. Many, and probably most, of the 273 people a year who die from heat in heat waves are the frail poor elderly.

While tens of thousands of adults are killed every year by trauma (homicides, suicides and accidents), the vast majority of these deaths are man v. man conflicts.

Car accidents and work related accidents involving some form of machinery, man made construction environments, or man made poisons predominant among deadly accidents. Also, quite a few of the deaths formally classified as accidents, usually slip and fall deaths, are basically deaths of old age, as the falls would have been minor events in the lives of a typically non-elderly adult. The solutions to man v. man threats are within our collective control.

There are also other diseases that kill non-elderly adults -- cancer, cardiovascular diseases, lung diseases and diabetes at the top of the pack among them. But, with the exception of cervical cancer, which is linked to the HPV virus for which there is now an effective vaccine, these are not communicable diseases. They are a product of hereditary predisposition, life choices and just dumb bad luck that we don't understand. They are threats inherent in who we are personally. Many suicides are really deaths as a result of mental illness. (Footnote: Are there any contagious, pathogen transmitted mental illnesses? Why not?).

It isn't that diseases that kill the elderly are unimportant. But, they are frequently contributing factors to an underlying malady known as old age. If cancer doesn't kill you, a geriatric fall, the flu, a heart attack, or some other failing organ likely will. Very few people live much longer than 100 years. No one has ever lived to be 130 years old. The ultimate causes of death for people over age 65 or so, are overwhelmingly those classically associated with the aging process. The warranty on a human being's component parts runs out. In a way, old age is very much like AIDS. Often it isn't the ultimate cause of death, but it makes other risks that could ordinarily be ignored, deadly.

The very young are particularly vulnerable to a wide variety of risks to their lives. But, parents on the whole do a better job of protecting their children than they do themselves. Children who survive the first year of life, through adolescence, have a lower mortality rate than any other age group, despite their heightened vulnerability to a vast array of threats and personal lack of good sense to protect themselves from all manner of injuries that adults have the good judgment not to expose themselves to. Most children who do die in the first year of life were born with the congenital defect that kills them and do so just days, weeks or months after being born. While abortions and miscarriages are common, infanticide, the ancient Roman predecessor to the abortion debate, has virtually disappeared and where it happens, usually happens now in the hours immediately following a birth by a teen single mother who was in denial during pregnancy and give birth alone.

No End In Sight

In contrast, there are a million people with AIDS in the United States. There is no cure, although anti-retroviral drugs can slow its progression. There is no effective vaccine, and devising one has proven difficult for reasons intimately connected to the nature of the disease itself. It has a long latency period, so most people who spread the disease don't know that they have it. This makes it hard to devise targetted ways of preventing those infected from spreading the disease.

There is also no precedent for wiping out a relatively widepread sexually transmitted disease. We've had a good working understanding of syphillis and ghonorhea for a century. Herpes is more recently understood, but still hardly the new kid on the block. None of these diseases on the path to erradication. Their prevalance has ebbed and flowed from year to year, but we've never come anywhere close to wiping them out. Yet, any strategy that would wipe out AIDS would, almost necessarily as a side effect, have to also virtually eliminate all sexually transmitted disease in the target populations.

Wiping out all sexually transmitted diseases in gay men, IV drug users, sex workers and African-Americans, the groups that have faced the brunt of the AIDS scourge in the United States, is a tall order. None of these groups are known for their pervasive blind obedience to governmental authority.

Given this fact, AIDS seems likely to remain the number one force of nature capable of killing non-elderly adults for the foreseeable future. This is why it deserves to be singled out for special attention. Damage control, and not elimination of this single greatest external killer, is the order of the day.

Lest I close on a gloomy note, I'll mention that there is a simple, low cost treatment that can provide resistance to the spread of AIDS and other sexually transmitted diseases. It is circumcision. When my son was born, the evidence wasn't so clear. But, now, the evidence is overwhelming that circumcision greatly reduces the risk of transmission of sexually transmitted diseases (by a factor on the order of a third to two-thirds). It isn't a vaccine, but it is cheap and easy, which matters in the case of a disease which, while my focus has been on the first world, is most severe in Third Would countries in Africa and Asia.

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