The Declining Importance of Infectious Disease
The most profound change affecting the health polity in the late 1970s and early 1980s was a major shift in patterns of illness, a shift with consequences for every individual and institution within the polity. Chronic disease had become the leading cause of disability and death. For half a century many people in the health polity had advocated changes in the array of institutions for treatment, in professional education, and, most important, in the financing of health care to take account of the growing prevalence of chronic illness. But the institutions of the health polity ac-
commodated slowly to the new epidemiological situation. Most physicians, hospital managers, and, most important, Blue Cross and health insurance executives behaved as if infectious disease, injury, and the acute phases of chronic illness were the major causes of sickness and death. Most of the resources allocated to the health polity were therefore spent to manage acute episodes of illness and their aftermath. Nevertheless, by the late 1970s the burden of chronic, degenerative disease in an aging population was stimulating a profound reallocation of resources, new assumptions about the responsibilities of individuals and institutions, and considerable concern about rising costs.[1]
In the 1970s, moreover, physicians, health officials, and journalists frequently described infectious diseases as problems that had been, or soon would be, solved by scientific progress and an improved standard of living. They usually defined the most pressing health problems as cancer, heart disease, mental illness, and infant mortality among the poor. In contrast, almost everyone knew the history of success in the struggle against infectious diseases during the past century. Smallpox would soon be the first infectious disease to be eradicated; measles would be the next target.[2] Controlling an infectious disease now seemed to be a routine process of discovering its cause and cure. It was no longer necessary, in the United States at least, to crusade for proper sanitation, housing, and diet in order to reduce the incidence of infectious disease. There was considerable evidence that, from the early nineteenth century until at least the 1930s, changes in diet and living conditions had, in fact, been more important than medical intervention in bringing most infectious diseases under control.[3] As a result of rapid scientific advance since the 1940s, moreover, many diseases that had once been leading causes of death had become brief, if unpleasant, episodes of illness. According to leading medical scientists, this success proved that research in basic science should have higher priority than efforts at care and cure.[4] By the early 1980s infectious disease accounted for "less than 5 percent of the costs estimated for all diseases in the United States."[5]
Sexually transmitted diseases (STDs) were now accorded lower priority than ever before as threats to health. Syphilis and gonorrhea were amenable to drug therapy. Public health professionals now considered treatment a method of controlling venereal disease. The availability of treatment, whether in public health clinics or the offices of private physicians, created opportunities for education as well as cure.[6] Although public health agencies still conducted vigilant surveillance, physicians reported a smaller number of their cases than they did in the past, in
large measure because they perceived venereal disease as less of a threat to the community.[7]
Just a few years later, some people would recall with nostalgia the general attitude toward infectious disease in the late 1970s. In 1986, for instance, a third-year resident, who had entered medical school at the end of the 1970s, lamented that "many of today's residents spent their formative years in medical training during an era when the ability of the scientific community to solve health care problems seemed limitless."[8] The chief of the infectious disease bureau of a state health department recalled that, before the AIDS epidemic began, he had been considering a job with the World Health Organization because his work in the United States had become routine. In 1987 the chief of the infectious disease division at a major medical school, talking about AIDS to first-year students, lamented that he had chosen his specialty because he liked the idea of helping patients to recover quickly from their illnesses.