Angels in America: reflections on HIV/AIDS and innovation in health care

Last night I saw Tony Kushner’s Angels in America – A Gay Fantasia on National Themes at Soulpepper. What a superb production of an epic play.

Like all great theatre, it delved into universal human themes that are relevant today even though the play was written in a different era (for me, Shakespeare and Chekov are the  masters).

Kushner’s play is about the early days of the AIDS epidemic in America. It premiered in 1991, and the play takes place between 1985 and 1990. The production heartbreakingly portrays the physical and emotional devastation of AIDS in those days, when survival was measured in months and many of the deaths of the (mostly) young men were miserable. This was made worse by society’s prejudice about, and hostility towards, homosexuality.

Despite the fact that 1985 isn’t very long ago (I was a young physician in London, Ontario at the time), it was striking to me how much the world has changed in the interim – for the better.

We spend a lot of time complaining about health care these days and not enough time and energy celebrating our successes. The development of anti-retroviral drugs is an unbelievable success story that we should not forget.

It was only six years after the first description of AIDS that AZT was shown to decrease death from HIV infection. This was obviously too long for the thousands of people who died from AIDS during that time. However, it is a remarkably short time in which to discover the cause of a new disease, develop a drug that might treat the virus, and show that the drug works with acceptable side effects

The play prompted me to re-read the report of the first randomized trial of AZT. After only 8 to 24 weeks of treatment, AZT decreased the death rate from 19% to less than 1%.  This one study of 282 patients transformed health care and people’s lives! And shortly thereafter, combinations of drugs were developed that changed HIV infection from a rapidly and universally fatal disease into a manageable chronic condition for individuals who live in countries where the medications are easily accessible.

There is lots of talk about innovation in health care these days, much of which isn’t. AZT was a true innovation. This story also highlights the importance of basic science research – without the rapid identification of HIV as the virus that causes AIDS and an understanding of how it replicates, AZT would never have been developed.

For me, Angels also illustrates that one other thing has improved markedly since the mid 1980s. Prejudice still exists within society. However, I was struck by the enormous advances that we have made in our attitudes towards homosexuality since the 1980s, some of which have been reflected in our laws. I suspect that the gay men in Kushner’s play would have been very surprised that Ontario’s Minister of Health in 2003 was openly gay, as is our current Premier. Same sex marriage has been legal in Ontario for some time. This too is worth celebrating.

The comments section is closed.

  • Mark MacLeod says:

    I agree completely Andreas with your observations. I also think that we see, since the 80s, the importance of highly goal directed research in the development of HIV therapies. Perhaps, not since the development of the atomic bomb have we seen such a project – where research dollars were invested and concentrated in a highly directed manner to find a treatment for HIV/AIDS. It’s perhaps worthwhile to wonder if such a goal directed strategy perhaps has a larger place in our research environment. As a non-researcher it might be already being done or it might be the wrong strategy but it seems an appropriate question to ask.

  • Judy Glennie says:

    An important commentary that helps us put into perspective what true innovation is and/or should be. Particularly relevant in the midst of recent concerns/protests raising the issue of whether policy makers understand the value of evidence, innovation, etc. – and the science and research that go along with it. Societally, we all need a reminder about the broad and systems-wide contributions that innovation and research make in our individual and collective lives. I fear we have started to take it all for granted. Thanks, Andreas!


Andreas Laupacis

Editor-in-chief Emeritus

Andreas founded Healthy Debate in 2011. He is currently the editor-in-chief of the Canadian Medical Association Journal (CMAJ)

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