In Memory of Dr Joseph Sonnabend, 6 Jan 1933–24 Jan 2021

Dr Joseph Sonnabend’s first concern was always the welfare of his patients, their families and the people they loved. Before HIV was identified as the virus that caused Aids, Dr Sonnabend was treating people suffering from the shocking illnesses that he and others were discovering among their patients in New York, mostly gay men. Many people infected in the 1980s died. But some survived because of the work of professionals such as Joseph. He pioneered safe sex as a response to HIV and Aids among gay men, and gave his patients the undivided attention that few others were prepared to give.  

Joseph set up and ran several institutions to address the epidemic, care for sick people and research the disease. But when some of his colleagues joined with other parties to create a myth about an imminent ‘heterosexual Aids’ pandemic in order to raise funding, he left. Joseph was branded a ‘denialist’ by those who didn’t wish to deal with any of the numerous concerns that he raised. However, Joseph continued to insist that you cannot understand the spread of a disease if you fail to identify the most important circumstances surrounding its transmission. He still held his ‘multi-factorial’ view of HIV a few months ago, in a discussion about the history of the pandemic with Sean Strub and Dr. Stuart Schlossman. When Schlossman claimed that no one held such a view any longer, Joseph disagreed, but did not have the opportunity to defend his position at that time.

Joseph told me later that his ‘multi-factorial’ view of disease transmission is a characterization of epidemiology as the study of pathogen, host and environment, and not an idiosyncratic theory of his own. He said that most people he worked with in immunology and epidemiology held a similar view, and did not reduce the explanation of HIV infection and the development of Aids to an account of the pathogen, alone, independent of host and environment factors. That’s why the multi-factorial view of HIV explains a lot more than its sexual transmission among men who have sex with men. The theory can also be used to understand the extraordinary outbreaks of HIV transmission among people who are neither male, gay, intravenous drug users, nor even sex workers. The worst of these outbreaks are all to be found in a few countries in southern and eastern Africa, including Zimbabwe and South Africa, where Joseph spent several decades of his life.

Joseph confirmed my belief that HIV is not ‘all about sex’ in high prevalence countries, and that the worst epidemics cannot be accounted for by alleged ‘unsafe’ sexual behavior among African people. He often asked how women can transmit HIV to men via sexual intercourse, saying he knew of no causal mechanism to explain it. Something about the host and the environment, African people and the conditions they live in, the experiences they have, the diseases they suffer, their crumbling healthcare facilities, their poverty and their position as former possessions of European powers could turn out to be a part of a credible explanation of the highest rates of HIV transmission in the world.

Joseph was concerned about the way people lived, their welfare, their “complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO’s definition of health, not necessarily exemplified by their activities). He was not content with vaccines and cures, treatment regimens and medications, alone. In fact, Joseph was opposed to what he saw as the rapidly increasing ‘medicalization’ of healthcare, and disgusted by the systematic humiliation of African people, who were blamed for their own sickness and told to quietly accept what they were given.

Many people have learned a great deal from Joseph, and benefited from his work. He distanced himself from those who saw HIV and Aids as a launchpad for their own careers and ambitions, and he refused to get involved in the more lucrative side of the pandemic. He will be much missed.