Plagues in World History (36 page)

A very different picture emerges of the Oceania region, encompassing Australia, New Zealand, and the Pacific Islands, where HIV prevalence rates are close to zero and a total of fifty-nine thousand people living with AIDS were counted as of 2008. The one exception is Papua New Guinea, which accounts for the vast majority of AIDS cases in the region and whose seroprevalence rate currently stands at 1.5 percent of the population. Here, heterosexual transmission seems to be behind the epidemic, but its true nature and extent is largely unknown due to the lack of good information available in a country that is highly rural and diverse.88 (Over 850 different languages and tribal societies have been identified in Papua New Guinea.) Reliable epidemiological data is also in short supply in the Middle East and North Africa, where HIV testing and access to ARV therapy remains low and the disease is associated with certain marginalized “high-risk” groups such as drug users, gay men, prostitutes, and migrant laborers.89 However, what information we have does suggest that the region’s epidemic is on the rise, increasing by about 65

percent during the first decade of the twenty-first century, with thirty-five thousand new AIDS cases, representing 11 percent of the total, in 2008 alone.90

To conclude, AIDS has always been a ripe disease for drawing historical paral els and analogies. At first, we natural y compared it to other, terrifyingly 176 y Chapter 6

deadly infectious diseases of the past, such as the medieval Black Death or plague, because it seemed to be all encompassing of our society, but as we learned of its continued entrenchment in certain high-risk behaviors, the relevance of this comparison seemed to fade. Now, AIDS seems to lend itself to being compared with other chronic diseases like syphilis, cancer, or tuberculosis, at least in their untreatable forms.91 AIDS is thus a kind of catchal for every social issue associated with disease. For example, transmission of AIDS involves some moral y stigmatizing behaviors that have also informed syphilis and some types of cancers. In its late, full-blown state it can be as disfiguring as leprosy or smal pox. Conditions of poverty, especial y in the third world, seem every bit as conducive to its spread as tuberculosis, with which it is opportunistically linked.

And AIDS in sub-Saharan Africa seems to be operating under the same victim dynamic as the influenza pandemic of 1918, in that it mainly targets people in the prime and most productive part of their lives while leaving the very young and the very old relatively unscathed. AIDS at times inspires fitful efforts at quarantine or ostracization, contact tracing, and other public health measures that conflict with individual liberties and that likewise were tried with plague, cholera, tuberculosis, and syphilis.

The late author Susan Sontag drew upon a rich array of these historical analogies in her famous book
AIDS and Its Metaphors
, but the counterintuitive lesson she took from it was that AIDS and other comparable diseases like cancer should be divorced from their social context and ideally approached in biological isolation in order to strip away their debilitating stigmas.92 The problem is we have already seen how apparently biologically neutral statements about heterosexual transmission or epidemiological origins of AIDS can nonetheless be charged with their own political and social agendas. From the very beginning, it was nearly impossible to disentangle the social construction of AIDS from whatever independently objective, biological reality it had. Its name and even very existence has been a matter of some debate and dissidence, while its origins, transmission, and spread are deeply rooted in our society’s variable trends and behaviors, on both a communal and a personal level.93 And yet, while AIDS does act as a kind of grand summation of all the diseases of the past, it also possesses some unique and distinctive qualities of its own. AIDS is less easily spread than other latent diseases such as tuberculosis and syphilis (although this can change depending on various cofactors), and this fact can affect how urgently measures to protect the public welfare should be implemented. Meanwhile, AIDS is perhaps more asymptomatic or else more easily masked by opportunistic infections than these other diseases during its long, slowly progressing incubation and dormant periods, allowing it to silently worm its way into a target population until it becomes endemic, despite the difficulty with which it is transmitted. It is a AIDS y 177

disease of the blood as well as of seminal fluids, and blood has always had a singular fascination for society as the precious bodily fluid of life. At least initially, AIDS was intimately associated with a particular subgroup of society, the gay community, that until then had not received much attention in disease history, or for that matter in human history in general. The timing of AIDS came right after the sexual revolution of the 1960s and 1970s, mixing sex and death in a particularly potent and frightening combination. Above all, AIDS forever changed the way historians view the history of disease, coming as it did right after victory had been declared against major infectious diseases like smallpox and as the medical community began to shift its focus toward more chronic conditions like cancer and heart disease. Even though AIDS at last seems to be joining the ranks of these latter, chronic diseases, the damage has already been done and historians can now never go back to the assumptions of the past: that human society will inevitably triumph over and find a cure for its ills, especially when concurrently or fast in AIDS’ wake has come other, exotic diseases like Ebola, bovine spongiform encephalopathy (“mad cow disease”), and hantavirus pulmonary syndrome. AIDS indeed changed the very definition of what a disease is, forcing recent historians to take a much more relativist approach to disease history. For teachers, it has likewise proved very useful for posing all sorts of questions with respect to disease, even as it has withheld all its answers, since its mysteries are still unfolding. AIDS has thus been a boon for people morbidly fascinated with disease like me. But even so, I fervently wish it had never come among us.

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Conclusion

Toward the end of the second millennium, in 1994, two books were published that both warned of a “coming plague” apocalypse. The Pulitzer-prize-winning author Laurie Garrett, after chronicling over a dozen frightful diseases that were “newly emerging” in a “world out of balance,” declared in her last chapter that our microbe predators now had the advantage over their macro hosts and would emerge victorious unless we changed our environmentally destructive ways.1

Similarly, Richard Preston, in his best-selling book
The Hot Zone
, which tells the story of an outbreak of Ebola and Marburg hemorrhagic fevers in central sub-Saharan Africa and at an army research lab in Reston, Virginia (which served as the inspiration for the 1995 film
Outbreak
), concluded in his final pages that “the earth is mounting an immune response against the human species.” By this he means that, as humans are destroying ecological environments such as the tropical rainforest, so does the earth, in a kind of role reversal, attempt “to rid itself of an infection by the human parasite” with the emergence of deadly new diseases, particularly the worldwide plague of AIDS.2 Continuing this theme, a new study relates our heightened disease environment specifically to the loss of biodiversity and natural habitat destruction, which increases our exposure to exotic pathogens by “homogenizing” or spreading them around the world, where they displace complex local species varieties.3 Such biodiversity loss would also deprive us of potential cures such as new antibiotic drugs that are desperately needed now more than ever, with the advent of hospital-raised “superbugs” such as methicillin-resistant staphylococcus aureus (MRSA) as well as drug-resistant strains of established diseases like tuberculosis and malaria. A good example of 179

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the consequences of our habitat encroachment is the sudden appearance of the deadly Hendra virus in Australia in 1994, around the same time as Ebola was wreaking havoc in Africa. In both cases, it seems these never-before-seen diseases were the result of destruction of or intrusion upon bat habitat, which allowed for once exotic pathogens harbored in a remote host environment to homogenize and jump species. Perhaps this is simply the Gaia effect, whereby mother nature on a global scale is simply correcting the imbalance of an exploding human population, which as of 2010 is approaching seven billion.4 The last time there was a major correction was during the Black Death in the late Middle Ages; since population has been growing largely unchecked ever since, it could be argued we are overdue for another one.

But in addition to failing to respect the boundaries of the wildlife ecosystem, which is an especially big problem because it is estimated that 60 percent of all diseases crossover from animals to humans, there are other large-scale factors at work, both environmental and otherwise, that will affect our epidemiological history: global warming, poverty, warfare, and so forth. It seems we are locked in a never-ending war with microbes, a war that has gone on ever since humans began altering their natural surroundings for their own purposes with the advent of agriculture and settled communities at the start of the Neolithic era some twelve thousand years ago. In some scholars’ schema, this was but the “first transition” to a new disease ecology, in which humans now had to live with a far greater prevalence and virulence of disease in their lives; a “second transition” is understood to have occurred with the advent of the agricultural and industrial revolutions during the eighteenth and nineteenth centuries, when populations, at least in the West, commenced a rapid expansion and began concentrating in urban environments as well as establishing colonies of themselves around the world, all of which were made possible by the more efficient production of food and creation of wealth and factory employment in the cities. The “third transition” currently under way is the product of globalization of disease environments, as already mentioned. But whereas most texts portray the emergence of so many new diseases since the 1980s and 1990s (such as AIDS, Ebola, mad cow’s disease, Lyme disease, Legionnaire’s disease, hantavirus pulmonary syndrome, SARS, and avian flu, to name just a few) as well as the reemergence of some old ones (such as tuberculosis, malaria, yellow fever, schistosomiasis, cholera) as being an unprecedented and alarmingly new phenomenon, it could actually be argued that all this is really just a natural extension of some ancient forces going back thousands of years, which include changing modes of subsistence, shifting populations, environmental disruptions, social inequalities, and so on.

We are simply entering a new stage in our age-old struggle with disease, one that now combines the worst of both prior transitions: more contact with new disease Conclusion y 181

environments and greater ease and speed of their spread among large numbers of people around the globe—nor ought all of these transitions be necessarily accompanied by a worsening of human health across the board. During the second transition, for instance, incidences of tuberculosis, smallpox, and cholera began to dramatically decline, helped partly but not exclusively by new medical advances, such as vaccination and the germ theory, although such benefits came considerably later to the developing world.5

At this point, we should remind ourselves that the germ of many of these ideas goes back to a notion first advanced by the historian William McNeill in Plagues and Peoples, and which has informed disease studies ever since: humans are “macroparasites” on their environments in a way that is analogous, and yet also mutually dependent upon, the relationship that “microparasites,” or disease microbes, have with us. Even should we be successful in our medical fight against disease, McNeill argues that this would only be a temporary victory, as the “gal-loping increases” in human population as a result would then put enormous pressures on our food supply and other resources that inevitably need to be corrected, a kind of global neo-Malthusianism.6 Although the rate of population growth seems to have slowed in recent years, estimates are that the world’s population will reach eight to nine billion people by 2050 and nine to ten billion by the end of the twenty-first century, unless unforeseen catastrophic pandemics (or any number of other natural or man-made disasters) intervene.7 The chance that we will self-impose limits or even reverse reproduction of our numbers seems remote. (Communist China’s “one-child” policy has so far had limited success.) Therefore, it seems assured that disease will play an inevitable part of human history for the foreseeable future.

The main themes of our future history with disease are ones that I identified already in the first chapter on plague. Travel, which now exists in the form of relatively cheap airfare that makes possible the reaching of almost every corner of the globe from almost any other within a day, will continue to spread disease just as Mongol trade routes spread the Black Death, although the process has been speeded up so much that exotic diseases once confined to remote places are now practically in our backyard. The winners and losers of disease will continue to fall along the fault lines of wealthier countries mainly in the West—which are better able to weather the storms of pandemics and, with their pharmaceutical conglomerates, might even economical y benefit from them—and poorer nations in the third world of Africa, Asia, and Latin America, which will bear the brunt of most disease mortalities, as India did, for example, during the Third Pandemic of plague and the 1918–1919 influenza outbreak. And medicine wil find its limits in successful y preventing and treating infectious diseases, especial y in this day and age with the emergence of so many new ills on nearly a daily basis.

182 y Conclusion

Nevertheless, I mentioned in the introduction that I personally am more hopeful, optimistic, sanguine, or however you wish to call it, than probably most other authors about humans’ future at the hands of disease.8 Perhaps this is partly because I live in Vermont, where over the course of little more than a century, deforestation and biodiversity loss have actually been reversed, to the point where today 80 percent of the state is carpeted with trees, whereas in 1880 only 20 percent was, and many wild animal species—such as moose, whitetail deer, black bear, and turkey—have been reintroduced to the state and are now quite commonly sighted. But the principal reason for my positive outlook goes back to one of the main theses I identified at the start of this book: humans have proven throughout history their power to alter the course of epidemics and pandemics, simply through their cultural conceptions about disease. To my mind, too many histories of disease still focus on the biomedical fight against microbes with our impressive and continually evolving technologies, such as genetic engineering. But the even faster evolution of microbes means that the dream of a “gorillacillin” superdrug to match the superbugs is probably unrealistic.9 It is likely then that we will forever have to fall back on our own cultural devices as at least some part of our future response to disease. This is why the history of that response such as we have been tracing in this book is so important and instructive. The SARS outbreak in 2003 is a good example of how a pandemic in the making was successfully contained, despite the fearfully fast pace of its spread, using tried and true methods of quarantine and information sharing among countries (after initial efforts at suppression in China); we perhaps benefited from our heightened state of readiness toward global terrorism. (In the event, the SARS scare was over in just a few months, but the stakes involved were demonstrated by the fact that in that brief time over eight thousand people in thirty-seven countries were infected, of whom eight hundred died.) And yet, I cannot help feeling that the focus in too many books with disease bioterrorism is rather overblown, given that most diseases through their natural modes of dissemination are terrifying enough.10 It should be of some comfort to us that humanity was able to survive even the horrors of the plague, with its average mortality of 50 to 60 percent during the medieval Black Death. Europe’s low-grade quarantines are still thought to have had some effect in helping to eventually end the plague by the eighteenth century, and our ancestors’ widespread belief in the afterlife may have helped psychologically “inoculate” them against the mass death due to disease. The British physician John Snow demonstrated how good old-fashioned detective work could provide the tools for tracing and conquering cholera in the mid-nineteenth century, well before the germ theory heralded our modern biological approach to disease. Some of our current difficulties, such as multi-drug-resistant tuberculosis or new strains of avian flu, are Conclusion y 183