HARVARD SQUARE COMMENTARY

March 10, 2008
AIDS, Evolution, and the Leper of Bethany

John R. Guthrie


In the early 1980’s, the new infectious disease specialist gave a lecture to County Medical Society. Though the lecturer was a capable and skilled physician, his presentation was drier than mummy dust. He mumbled his way through, speaking of an unusually high incidence of an obscure type of cancer called Kaposi’s sarcoma and also a dramatic rise in the occurrence of Pneumocystis pneumonia caused pneumonia. These phenomena seemed related in a way ill understood to a previously unheard of virus called the Human Immunodeficiency Virus. When the speaker finished, we breathed a collective sigh of relief and left.

Months went by. A new patient we will call Gerald Frey came to my clinic. Among the things I realized early on concerning Gerald was that he was one of the most unpleasant young men I’d met. Sadly bitter, fractious, unreliable and untruthful, he was certainly not the sort of patient that one would sentimentalize.

He worked in an industrial abrasives plant out in the county, one of those new industries that had migrated southward to enjoy the cheaper wages and more pleasant climate of the South Carolina Piedmont. He lost his balance and got his left arm caught in the rollers of the machine he tended. The abrasive roller of the machine scraped away the full thickness of the skin covering his left armpit, right down to muscle and sinew. For reasons that became understandable to me only later, he had deferred getting medical care. When he saw me that first time, the left armpit was varying shades of black and red, draining pus and exuding a foul odor. I admitted him, feverish and weak, to the Regional Medical Center an instituted a course of intravenous antibiotics.

In the hospital and then as an outpatient, cleanup or debridement of the wound was carried out to remove the slough of infectious material. After a few weeks, the surgeon was presented with a clean and pink wound ready for skin grafting.

The patient was rehospitalized. A dermaplane, an electrical device that functions like a vegetable peeler, was used to harvest skin from the patient’s thigh. The section of skin was then run through a machine that perforated it so that it becomes a grid that could be stretched to cover a greater area. The surgeon stitched the graft into place and kept it moist with a saline dressing. Ninety five percent of Gerald’s graft survived; a good result.

Yet soon after discharge, Gerald was back in my clinic. He had a difficult-to-resolve sore throat and severe lassitude. Like the biblical Job, he then endured a plague of boils of such intensity and severity as to require hospitalization and intensive IV antibiotics again.

The infectious disease physician’s lecture bubbled back to the surface. I ordered a Western Blot, a test for the HIV virus. It is a screening test, not terribly accurate, but easy and inexpensive. It was positive. The confirmatory test, more expensive and reliable, gave the same result. Gerald was my first AIDS patient.

It was at about this same time that the minister of Spartanburg’s First Church pronounced from his pulpit that AIDS is God’s judgment on gays. He didn’t comment on the unfortunate children and accident victims who get AIDS from tainted blood or the women and men in Africa and Asia, where AIDS is primarily a heterosexual disease. God’s collateral damage, one supposes. Others in the community at large felt much the same way, and called for measures such as the imprisonment of those infected with HIV.

The Human Immunodeficiency Virus, the AIDS virus, is a string of ten thousand or so nucleic acids, code words made of nucleotides strung together like a string of beads. Once in the host’s body, the virus favors cells that constitute the body’s defenses against invading germs; the immune system. Like commandos taking over a factory, the virus tricks the DNA of the host’s immune cells into making copies of itself. Billions are churned out. The immune system attempts to fight off the invader, but eventually collapses under the effort, leaving the patient unprotected against infections and certain cancers.

The virus is not particularly good at producing accurate copies of itself. In this very imperfection, an error rate something on the order of one per thousand, resides the virus’s great power. Many but not all of the new generation of viri are such poor copies that they simply die off. But a miniscule few defective copies have changed in useful ways. The virus, like other living creatures, modifies to cope with whatever challenge is present.

Retrovir, one of the earliest antivirals, showed great promise in combating AIDS early on. Yet it proved to be highly effective only for a matter of months. Those lucky few viri, those that evolved so that they could endure Retrovir, survived and replicated.

These modifications in the HIV are exactly that described by Charles Darwin in larger creatures, be it finches, whales, or humans. That is, the principles of evolution for the AIDS virus are precisely the same as those that brought us from the Australopithecines of the African Savanna to contemporary human beings.

The host evolves also. It has now become evident that some few humans have resistance to AIDS, just as there were those fortunate few who had resistance to the Great Pox, syphilis. With the virus, reproduction occurs so frequently that the process of evolution is readily observable over the short span of a human life. The evidence is as incontrovertible as the evidence gathered by Copernicus for the earth revolving around the sun instead of vice versa. It is a great misfortune that particularly in this country, many would deny our children accurate information about the evolutionary process that is one of the crucial cornerstones of modern biology and medicine.

Over a dozen different subtypes of AIDS have been identified. Each is specially tailored through evolution to fit its particular host population whether in the 1980’s bathhouses of San Francisco or the contemporary brothels of Bangkok.

The HIV virus has cousins, different branches on the same evolutionary tree. These occur in species as different as dolphins and chimps. It became a human pathogen, skipping the gap of genus and species, through evolution.

But what of the patient, Gerald Frey, the irascible young man who suffered such great affliction? I wish I could tell of a great clinical triumph; the heroic salvation of his damaged body as well as his embittered spirit. But it was far too early in the AIDS game for that. His clinical course was essentially that of steep decline, then, “Out, brief candle!”

Yet we have learned much from Gerald and others so afflicted. AIDS is more and more a survivable disease. Knowledge of evolution and the scientific principles derived from it has engendered new drugs for treatment, drugs such as the protease inhibitors. And like the light before the dawning, the promise of a vaccine in the near future is a bright one.

But quite aside from the prodigious work of Darwin that unlocked so many of the treasures of nature’s storehouse, and aside from the useful information gathered in the austere reaches of the research labs, there is another dimension of things to be learned from this tale.

AIDS is to our time much the same as leprosy was in biblical times. If you look into that splendid compendium of myth, history, struggle and survival, the Bible, you find that in the furthest reaches of biblical history, lepers were cast out. They had so offended God that they couldn’t even be buried in the same cemetery as the righteous. The attitude in the early days of biblical history toward lepers is quite like that demonstrated by certain members of the community today towards AIDS sufferers. In a Meals-on-Wheels program I was affiliated with, certain volunteers, church people all, refused even to deliver meals to those in the community who had AIDS. But that attitude, that grim and petty meanness born of fear and ignorance is certainly not the final and definitive attitude toward AIDS, or, for that matter, toward gays.

In the book of Mathew, one finds passing reference to leprosy. Jesus, while in Bethany, ate at the house of one known as Simon the Leper. There is great hope as well as a sterling example in this. Here, compared with the vicious ostracism of Leviticus, is evidence of evolution also; not of our physical selves, but an evolution of the heart. That the young Jewish revolutionary, that troublemaker Jesus, deigned to eat with a leper isn't surprising. After all, it was Jesus at his very best who befriended the “fallen” woman. He showed in the beatitudes great compassion for the poor, the weak, the outcast, the prisoners in their dungeons of despair who were exiles in their own land.

And similarly this time of ours is a time of sometimes troubling change. There is much hope provided by the bright and unflinching light cast by Darwin’s work and other scientific advances. Yet for some AIDS sufferers and for many others, it is still a time of despair and suffering. Thus more than ever, there is the need for the gospel of the redemptive power of love; a willingness to break bread with the Leper of Bethany.


This essay is derived from a speech delivered at MIT, Cambridge, Massachusetts, 2005.


John R. Guthrie is a former Marine infantry rifleman. He them garnered a formal education to include medical school and became the commanding officer of a U.S. Navy Reserve Shock Surgical Group before going into private practice in the Smoky Mountain foothills of Appalachia. He is the editor and publisher of the monthly webzine The Chickasaw Plum: Politics and the Arts Online. (Link)


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