Seventy-four years ago a viral pandemic began in America, most likely on a pig farm in Iowa. Fifteen months later it had killed over eighteen million people, 1 per cent of the world’s population, as many as died in two world wars, almost ten times as many as have died in a decade of Aids. The virus, transmitted by airborne mucus and saliva, spread via coughing and sneezing. In San Francisco and other American cities public health officials warned against all body contact, including shaking hands; ordinances were issued forbidding citizens from appearing in public places without face masks. Possibly because of such measures there were only a few thousand deaths in San Francisco during the first year of the pandemic, but elsewhere, including Europe, the toll was much higher. In Alaska and Central Africa and Oceania entire communities were wiped out. In India, it is estimated, the virus claimed twelve million victims–4 per cent of the population.
In statistical terms it was the greatest natural disaster since the Black Death, yet the Great Influenza Epidemic (or Pandemic) of 1918-19 has almost vanished from public memory. Unlike the war that immediately preceded it, the flu has left scarcely a trace in modern literature; historical accounts of it are sparse. One of its few chroniclers wrote, “the Spanish Lady inspired no songs, no legends, no work of art.” There are, in fact, two or three short stories about it—reclaimed by Barbara Fass Leavy in To Blight With Plague—plus a couple of book-length historical accounts and a handful of articles in scholarly periodicals (the African response is considered, inter alia, by Terence Ranger in Epidemics and Ideas). There is also Oliver Sacks’s Awakenings, on the outbreak of encephalitis lethargia that was triggered by the flu. But that’s about it. Most people know more about smallpox, or the bubonic plague of 1665.
Why should this be? It is an enduring puzzle. The flu was unprecedented in its virulence and global in its effects. Yet it came and went like a noxious fog, like something outside human understanding.
How we all became health workers
Aids (or HIV-disease, as some medical authorities are now calling it)—which, according to estimates from the World Health Organisation, has caused the deaths of two million people, has, by contrast, engendered a scientific and lay literature so vast that it defies easy summation or analysis. WHO estimates that several thousand people become infected with one or other of the strains of HIV every day. This figure is almost matched by the number of articles, bulletins, statistical records, conference papers, research proposals, press reports, newsletters and books about Aids and HIV that appear in the same space of time. A single issue of the Aids Newsletter, for example—itself just one of many such newsletters—summarises more than a hundred published items in European languages alone.
Of course it is not just a question of the scale of scholarly and journalistic production. The multiple epidemics have changed social arrangements. But these changes are, to a large extent, the result of the unprecedented level of information exchange. Aids has been the occasion for previously unheard-of co-operation between marginalised groups and the institutions of public health; it has given rise to a genre shift, a novel interpenetration of scientific and popular discourse. It has brought about what seems to be a permanent alteration in public perception and ways of talking about sex. There have been significant—if not permanent—modifications in sexual practice and rapid innovations in public health policy in both industrialised and non-industrialised countries. And all this with the exact cause of the disease still in dispute, without much in the way of effective treatment, with no vaccine in sight, and no cure. Although the full social and demographic effects have yet to make themselves felt, the disease has already entered the culture at so many levels that it is hard to imagine that it could be forgotten, as the Great Flu has been, even if a cure—or more probably a vaccine (since viruses generally cannot be extirpated without killing their host)—were announced tomorrow.
There are manifest differences in the epidemiology of Aids and that of influenza, which go some way to explaining why the Great Epidemic was so swiftly forgotten. Being contagious, influenza was—and is—more easily transmitted; its trajectory through a population is more rapid. The fatal flu of 1918 came and went in a couple of years; it took only weeks to dispatch its victims. They had little time to reflect on their condition. The high-risk groups were the same as with most diseases—children and the old, the least articulate—rather than those in the prime of life (though Aids, of course, kills children too). This was just as well since, in Europe at least, death had already reaped its harvest of male adults in the trenches of the First World War. There was no effective treatment for flu; and none of the confidence in scientific medicine that later successes in the treatment of infectious diseases bred in medical researchers. Although the 19th-century revolution in public health had already transformed the ecology of disease in Western countries, the 20th-century triumphs of curative medicine were yet to happen.
Aids gives us a glimpse of how most people in the world have always died: painfully, usually at an early age. It undoes the work of antibiotics, reshaping the sexual world into an era before penicillin and the pill, restoring the possibility of tragic consequences to the sex act after its brief run in the antic realm.
The triumphs of medicine, of antibiotics in particular, and the air of hubris they engendered in medical research are, of course, one reason for the unprecedented intensity of concern with Aids. The successful treatment of sexually transmitted diseases with antibiotics is generally acknowledged to have been, after oral contraception, the main factor in the post-war sexual revolution. Aids, though, has brought the sexual revolution up short, and, at the same time, in the public mind, delivered a blow to medical triumphalism. It has also, paradoxically or not, extended the hegemony of public health: sex now carries a statutory health warning. The apparatus of mass communications has been adapted from the task of fostering desires to that of curbing them. The medical establishment—in Britain in the form of the Health Education Authority—has recruited the public to an unusual degree in a programme of preventive sexual medicine, promulgating a form of hygiene analogous to that practised in the clinic. We are all health workers now: rubber gloves in the operating theatre; condoms in the bedroom. The ultimate transgression is to be without protection. The condom, barrier both to conception and to infection, is an emblem of this new dispensation. It is the triumph of the prophylactic.
Outside the old industrialised countries, in parts of the world where fewer people are exposed to television and newspapers, the missionaries of preventive medicine are at work. With workshops and task forces, comic strips and puppet shows and morality plays, they are spreading the gospel of safe sex. In Brazil, for example, Obaluaiyé, the Yoruba smallpox deity, is invoked in strip cartoons aimed at the followers of Afro-Brazilian religions. In Uganda, I noticed on a recent trip by land from Kenya, billboards greet the visitor at the border.
“Love Carefully,” they proclaim, with elegant solicitude:
Beware the Sweetness and Splendour of Sex.
It Can Be Dangerous to Your Life and Health.
In urban centres in African countries, where prophylaxis of any kind was unheard of a few years ago, there is a sudden deluge of subsidised condoms. The brand is called Prudence.
“Anywhere you can get Coca-Cola,” one aid worker in Uganda told me, “you should be able to get a condom.”
How different is Aids?
Recent advances in virology and new theories of the geographical origin of HIV may be changing medical ideas about Aids. These developments are beyond the scope of this essay. What is discussed here is the special place Aids is carving out in the history of disease, followed by a consideration of particular aspects of this: the gay literature of Aids and the perception of the epidemic in countries outside the industrialised West. To what extent is it the nature of the disease itself that makes Aids different, engendering these remarkable alterations in human behaviour? And to what extent it is rather a question of timing, of the point in human history—in medical and cultural history—at which it has made its fatal entrance?
Andrew Nikiforuk, a Canadian journalist, argues in The Fourth Horseman that Aids is not as different as we suppose. The pandemic is driven by a familiar conjunction of economic and biological circumstances, which he refers to as the “dismal economies of prostitution and urbanisation” and the “goat-like behaviour of single men”. Just as the Black Death found easy victims in populations weakened by decades of malnutrition, he says, Aids—in the West—found its first targets in people whose immune systems were already compromised by stress of one kind or another (‘excess’ is the word Nikiforuk uses). HIV, he says, piggybacks on existing sexually-transmitted diseases; Aids itself is multifactorial—i.e. it is not caused by HIV alone. This has not been the orthodox view until recently, though variants of it are now supported by an increasing number of Aids researchers, including Luc Montagnier, the discoverer of HIV (Montagnier posits a single co-factor, mycoplasma). But Nikiforuk doesn’t have much time for doctors in any case; his romp through microbial history is animated by deep suspicion of medical authority and scepticism about attempts to control disease. He compares AZT, the only available treatment for Aids, to the mercury treatment for syphilis. And he foresees, without much authority, a syphilis-like future for HIV—mutating, coming and going, different strains in different places.
The Fourth Horseman presents a cartoon history of epidemics, history as written by virus and bacterium and spirochete: in medieval Europe, Nikiforuk argues—or asserts rather—the plague provoked a labour shortage and thereby ended feudalism; in the New World in the 16th century smallpox defeated the Incas and the Aztecs; civil war in Sri Lanka, he says, is the result of overpopulation caused by the eradication of malaria. Civilisations, he proposes, are built on disease and are brought down by disease; all are under the domination of the great viral-bacterial superorganism.
It is not necessary to endorse Nikiforuk’s ecological misanthropy, nor his monocausal view of events, to find some insights in his historical survey. Aids, by its nature, embraces the history of disease: it strips away immunological history, rendering its victims open to infections that were thought, at least in industrialised countries, to be things of the past. As Lewis Thomas points out in his contribution to In Time of Plague, it gives us a glimpse of how most people in the world have always died: painfully, usually at an early age. And Aids, in another sense, returns us to the condition of our more recent forebears: it undoes the work of antibiotics, reshaping the sexual world into a simulacrum of the era before penicillin and the pill, restoring anxiety and the possibility of tragic consequences to the sexual act after its brief run in the antic realm. Thus the history of disease, particularly the history of sexually-transmitted diseases, is unusually relevant to understanding the present epidemic. We need to look to other authors than Nikiforuk, though, for balanced, scholarly historical accounts of particular epidemics and the endeavours that have been made to combat them.
Instead of promiscuity there is “high-risk behaviour”; there are “persons with Aids” instead of victims. But these new terms cannot contain the awfulness of Aids, or hide the deep fears enfolded in it: fear of sex, fear of death, fear of authority, xenophobia, homophobia, melanophobia and paranoia.
Carlo Cipolla’s Miasmas and Disease is an elegant account of public health measures in 17th-century Florence: measures which were developed as a result of plague epidemics in preceding centuries and which involved detailed documentation of outbreaks of disease and movements of people as well as sanitation and other public works. Diligent though they were, the inspectors of the Florentine sanitation office were limited by ignorance of the true means of transmission. The elimination of non-contagious infectious diseases from industrialised countries, Cipolla points out, has been achieved largely by identifying and eliminating the insect and/or rodent vector. Contagious diseases, those passed directly from one human being to another without insect or other mediation, are more refractory. Consequently plague, typhus and malaria—common in pre-industrial Europe—are now rare outside the tropics, but influenza and syphilis are not. Aids, flu, tuberculosis and the sexually-transmitted diseases belong to a small group of infectious diseases that affect populations in every part of the world. Flu, syphilis and TB have been around for a long while; Aids has not, but it may be yet.
The closest parallels to Aids in epidemiological terms are syphilis and Hepatitis B. In the case of syphilis, Michael Adler, in Aids and the Epidemics of History, lists as the chief points of similarity the sudden appearance of syphilis (at the end of the 15th century), its asymptomatic carrier state and predominantly sexual means of transmission. Hepatitis B, as Baruch Blumberg explains in In Time of Plague, is a still closer analogy: like Aids and syphilis, it is frequently sexually transmitted and has a long asymptomatic stage; like Aids it is common among Africans, homosexuals, haemophiliacs, intravenous drug users and the new-born children of infected mothers; and like Aids it is a viral disease. But there is a difference: there is a vaccine against Hepatitis B, developed in the late 1970s. There is no vaccine for syphilis—and a new syphilis epidemic may be developing in the wake of Aids.
How close is the analogy with syphilis in the field of public health? G.R. Scott argues (also in Aids and the Epidemics of History) that the present state of knowledge about Aids parallels that of syphilis in the 1920s or 1930s: the cause of the disease and the means of transmission are understood, he asserts (perhaps too confidently); and there is a test and a treatment, but the treatment is not a cure. At that stage with syphilis, he maintains, even before the introduction of penicillin, the number of cases began to fall. In the case of HIV the same conditions pertain, yet the number of cases continues, everywhere, to rise. There arc, he says, two reasons: there was routine testing of those at risk of syphilis infection, particularly in the military, and contact tracing of those who were infected, so that their sexual partners were also aware of their at-risk status. In the case of Aids, he argues, more of those at risk have to be persuaded to come forward for testing; and they must be more effectively persuaded to modify their behaviour to prevent the infection of others. Scott, a medical doctor, criticises, by implication, the tenor of public-health advertising in this country, which stresses everyone’s vulnerability, rather than the moral responsibility of the afflicted to avoid transmitting the virus.
Moral neutrality, public speech, new euphemisms
STDs pose special ethical and practical difficulties for doctors. These have, of course, been extensively debated in relation to HIV testing. If the rights of patients are more scrupulously respected today than in the past it is perhaps because the level of public awareness of the implications of seropositivity is much higher. This is to a significant extent due to the efforts of the medical establishment itself. Syphilis was brought under control—temporarily—at a time when public discussion of sex, let alone homosexuality, was still swathed in the impure hush of the Victorian-Edwardian era; the anti-Aids campaign, by contrast, takes place in the glare of media attention. The additional stigma attached to Aids, and the dire prognosis, may also discourage self-referral on the part of the high-risk but symptom-free.
The strenuous attempt by the medical establishment to get everyone worried, despite the statistically low incidence in the old industrialised countries of HIV infection outside specific high-risk groups, has become a target of criticism for other, less reputable reasons than those suggested by G.R. Scott. Is it not, some critics ask, a disproportionate expenditure of public money on a statistically insignificant problem? Hasn’t the risk of infection and the rapidity of its spread to the general population been exaggerated? Some suggest that the whole programme of Aids research and prevention is the product of an opportunistic medical establishment in league with the pharmaceutical industry and a vocal gay lobby, conspiring, consciously or unconsciously, to pump up the volume. The grim Schadenfreude that tempted gay activists to say to the straight world “You’re next, you know” may now be greeted by a straight, white response, albeit sotto voce, “Oh no we’re not”.
Such critics should reflect, though, that it may be the campaign that has contributed to the slowness of the spread of Aids, that high-risk groups form, in this sense, a cordon sanitaire protecting everyone else. They might also reflect on the acceleration of the spread of AIDS in the rest of the world, where sexual minorities are clearly not the main vector, and whether this might not be as much a matter of general concern as the epidemic on their doorstep.
What really irks Aids naysayers is, perhaps, not so much the alarmist tone of the public health campaign as its careful cultivation of moral neutrality. It is, in fact, the signal achievement of current official health discourse to treat homosexual acts and needle-use as though they involved occupational hazards—as mining does, say, or mushroom-picking. But this new official discourse is, of course, itself moralistic in its sedulous avoidance of moral judgment. With syphilis the treatment and the cure came before acceptable public speech; with Aids the establishment of a politically correct way of speaking about the epidemic has been an important part of the public health campaign. New euphemisms are promoted by an alliance of officials and gay lobbyists. So instead of “promiscuity” there is “high-risk behaviour”; and there are “persons with Aids” instead of “victims”. These terms may serve their purpose in drawing attention to the stigmatising effect of the vocabulary they replace, but they cannot contain the awfulness of Aids, or hide the deep fears enfolded in it: fear of sex, fear of death, fear of authority; plus xenophobia, homophobia, melanophobia and paranoia.
Despite the public health campaign, 50 per cent of African Americans, according to one survey, believe that Aids is the result of a government plot to kill them (can this survey really be accurate?). There are comparable gay conspiracy theories; and a radical Left notion that the pandemic is a fiction concocted by medical authorities to scare the general population back into monogamy. Doubtless, somewhere, there is someone who argues that it is designed to extend commodity fetishism via Third World dependence on Western condom-manufacturers. But such paranoid notions should not obscure the fact that there are ways of thinking and talking about Aids that lie outside medical and academic discourse that are still worthy of our attention.
Many of those most at risk of Aids still live in villages without public sanitation, without pit latrines even. In places like these you are lucky if you can afford a mosquito net to protect yourself against the increasing threat of malaria, let alone a condom.
In an article four years ago in the LRB (19 May 1988) I suggested that one of the effects of Aids, the result of its simultaneous restraint on sexual practice and liberation of public discourse, might be a refinement of sexually explicit writing, a silver age of erotica. This prediction was altogether too genteel. What we have—in England and America at least—is an epidemic of sex-at-a-distance, dirty talk in the ether (recently recycled for literature in Nicholson Baker’s phone sex directory, Vox). There has been a literary response to Aids too, but it has little to say, it seems, about sex, though quite a lot about other aspects of the body.
The deepest responses to the epidemic come, understandably, from the communities most directly affected by it. Although there is no haemophiliac literature of immunodeficiency, as far as I am aware, nor any notable work by—or about—intravenous drug-users with Aids, there is a vigorous artistic response from the African Aids epicentres in the realm of plastic art and popular music. And in the West, of course, there is a substantial gay literature, with French and American and British authors at the forefront. As Aids subsumes other diseases, capsizing its victims into a sea of afflictions, one might initially expect this art and writing to be rich in reference to earlier representations of sickness and health, to embrace the symbolism of other diseases in the same way that historical scholarship has taken the occasion to look anew at the epidemics of the past. In fact, though, much of the literature of Aids is dedicated to resisting these analogies.
In the United States the response of gay writers has been more political than it has elsewhere; while in France it has taken a ferociously introspective turn exemplified by the late Hervé Guibert, whose writings from 1990 to 1992 form a sequential and more-or-less autobiographical account of the process of dying. In Britain, gay writing about Aids, if one may generalise from a few instances, has been less melodramatic than either, less obsessed with symptomatology. It has been a discourse of quarantine rather than fever. Adam Mars-Jones’s stories, which have been appearing since the mid-Eighties, are quite unlike Guibert’s autonecrophobia. And they eschew almost all reference to public events, concentrating rather on the phenomenology of bereavement, the death-in-life that characterises the relationships of those affected by Aids. The buddy system, the pairing of people with HIV or Aids with lay volunteers who provide assistance and companionship in the course of the illness, is a recurrent narrative device in Monopolies of Loss. It is more than a narrative device, in fact: it creates an intimate distance between characters, emblematic of the change in gay culture, where every bodily transaction has become a reminder of mortality, where sex itself is subsumed under the sign of decay. The absence of gender difference, the absence that defines homosexual relationships, is displaced by a greater difference: the difference between the living and the dying, between HIV-negative and HIV-positive, buddy and victim, bereaved and deceased—or deceased-to-be. Told from one side and then the other, the stories spell out a thesis and antithesis of loss, the insights that are contingent on imminent death.
The stories are characterised by a punctiliousness of diction, a curbed, celibate style, a wariness with metaphors, a careful avoidance of pathos or sentimentality: the first story, “Slim”, originally published in 1986, eschews the Aids-word altogether. This stylistic austerity, this verbal denial, has, perhaps, an analogue in sexual restraint, and in the regimen that people with Aids must follow. There are some good jokes in Monopolies of Loss, but they fall like light on a black hole, swallowed up by the gravity of the subject. Many of the stories end, likewise, without resolution, as though Aids itself was the plot, the plot of plots, subsuming all sources of narrative tension. Mars-Jones himself compares the book to the Aids quilt, that vast, home-grown communal memorial to the Aids dead of America. Like the Aids quilt, like the Aids pandemic, Monopolies of Loss has a not-yet-finished quality about it, but the detail of the needlework is precise and telling.
The many names of Aids
“Slim”, the title of the opening story in the Mars-Jones collection, is a Ugandan term for the disease that appeared in communities round Lake Victoria in the early Eighties. “Slim” is just one of the many names of Aids in Uganda. In Rakai district, one of the epicentres of infection on the Lake, Aids is referred to by the Luganda terms namuzisa (“the one-that-causes-extinction”), mukenena (“the one-that-drains”), or mubbi (“the robber”). In Malawi, where 37 per cent of the population have been estimated to be HIV-positive and where health officials criss-cross the country issuing warnings against the disease, Aids is called matenda a boma, the “government disease”. In Tanzania, as reported by Tony Barnett and Piers Blaikie in Aids in Africa, the acronym itself has been recast, in a spirit of gallows humour, as Acha Iniue Dogodogo Siachi, a Swahili phrase meaning “Let it kill me as I will never abandon young ladies”. And in Côte d’lvoire, Sida, the French version of the acronym, is jokngly held to stand for Syndrome Imaginaire pour Décourager les Amoureux.
Gallows humour? Ignorance? Fatalism? What is the meaning of this creative plethora of names? One thing they indicate is how the meaning of Aids changes with distance from health services. The tragedy of countries like Uganda and Malawi and Tanzania is that the public health campaign cannot catch up with the spread of the virus. Despite efforts to import Western style preventive medicine, many of those most at risk of Aids still live in villages without public sanitation, without pit latrines even. They are living in the 20th-century equivalent of the Florentine communities described by Carlo Cipolla. In countries like these you are lucky if you can afford a mosquito net to protect yourself against the increasing threat of malaria, let alone a condom, even a subsidised one.
It is not the first time that attempts have been made to extend a particular programme of preventive medicine to the world outside the West. Maryinez Lyons describes (in Aids and the Epidemics of History) the misguided campaigns against sleeping sickness conducted by colonial authorities anxious to prevent decimation of the labour pool, but unaware that it was the European intervention itself and resultant population movements that had triggered the spread of the disease. Without the support of educational programmes, without access to health services, local knowledge of Aids may relapse into folk wisdom, a fatalistic attitude to a disaster whose causes are unknown.
Examples of this are not hard to find in Africa; a year or so ago I attended the opening of a health centre in West Nile Province in the north of Uganda. The four-wheel drive vehicle bearing the District Medical Officer arrived with the slogans of the Ugandan anti-Aids campaign painted on its doors in English: “Love Carefully”, they proclaimed, “Zero Grazing”. The Medical Officer, and the Chairman of the National Resistance Council both gave speeches in the same vein. Then the local bow-harp ensemble, the Laufori All-Stars, appeared. They had been commissioned to compose a song as part of the local anti-Aids campaign. Translated from the language of the Lugbara, the song, with its call-and-response structure, went like this:
There is a new disease
A new disease
There is no cure
There is no cure
If you catch it you must wait patiently
Until you die
Until you die
Most of the outsiders present were unaware, but somewhere between the capital and West Nile the anti-Aids message had slid from the preventive to the fatalistic.
In countries like Uganda (the focus of Barnett and Blaikie’s study), the financial insecurity of women promotes the commodification of sex. This is not simply a euphemism for prostitution; it refers to the multiple relationships that many women must maintain in order to survive and raise their families. Sex is not recreational for them; it is their means of survival. In order to follow the official recommendation to love carefully they would need to be less poor. So public information alone will not affect the course of the epidemic; more important is to change the economic forces that enjoin such sexual liaisons–and tolerance of male promiscuity–on women. The best hope for stemming the spread of Aids, Barnett and Blaikie argue, lies, to use current development jargon, in empowering women. Quite how this is to be done is a tricky question. The spread of Aids was triggered or exacerbated by social change. The challenge of prevention is to induce further, controlled social and behavioural change. But it won’t be quick enough.
It is clear now that the effect of Aids on the social fabric of certain African countries —and some in Asia too—is likely to be very grave. Aids in the West is not going to set back state formation, or decimate the skilled workforce, or create a generation of motherless children, but that is what it is already doing in Uganda. As Bamett and Blaikie put it, it is a long-wave disaster, spreading fast but killing slow. In non-industrial countries Aids may continue for centuries, becoming endemic as Andrew Nikiforuk predicts. Whatever happens it is not likely to vanish like the killer flu did.
Meanwhile the global cultural effects of Aids—the end or diversion of the sexual revolution, the worldwide extension of the means of mechanical birth control—are likely to last longer still. The enduring literary and artistic response we can only guess at. It may spring, not from the West—where for many Aids is still a disease of the horizon, something that does not affect them personally—but from one of the unlucky countries, the countries of the south, beyond the horizon, where the extent of suffering is much greater and the need to give it meaning correspondingly more urgent. ★