Conclusion: The End of the Struggle?

The biomedical approach to venereal diseases had been stunningly successful. Diseases that only ten years before had been described as the most serious of all the infectious diseases had now been tamed by chemotherapy with a simple, safe, and effective cure. Diseases that twenty years previously had been guilty secrets, virtually unmentionable in the press and quietly ignored by health departments, now became glorious examples of the triumph of modern medicine in overcoming ancient plagues. The ideological struggle between those who had seen the fight against venereal disease as a battle for sexual morality and those who had seen it as simply another form of bacteriological warfare was over. The social hygiene reformers had to concede defeat to the public health officers, epidemiologists, and laboratory researchers. Or did they?

In 1947 the Maryland State Department of Health, announcing the

success of the rapid treatment program, concluded its press bulletin with the warning: "To decrease the number of repeat patients and prevent venereal diseases it will be necessary to reduce sexual promiscuity. If fear of disease is a less powerful restraining factor the problem must be attacked more strongly through moral training and suppression of prostitution."^[74] Baltimore's health department sounded even more pessimistic: "It may be stated that so far there is little or no evidence that the apparently miraculous one and eight day cures of gonorrhea and infectious syphilis (respectively) with penicillin have accomplished much toward the control of these diseases. . . . Certainly this new therapy has done nothing to correct the promiscuous sexual behavior which is the ultimate cause of the spread of venereal disease."^[75]

In 1948 Thomas B. Turner, the prominent bacteriologist at Johns Hopkins, gave a talk to the American Social Hygiene Association entitled, "Penicillin: Help or Hindrance?" His title alone expressed a curious ambivalence about the new "miracle drug." As head of the Hopkins research group on syphilis, Turner was in a better position than most to understand the extraordinary difference the new chemotherapy had made to patients. He catalogued the successes of penicillin "on the credit side of the ledger" but cautioned that nobody should be "dazzled by the apparent potentialities of this fine new drug." On "the debit side of the ledger" was the loss of fear as a deterrent to exposure and the possibility of multiple reinfections; Turner assured his audience that the real concern of venereal disease prevention programs was "the moral, spiritual and economic health of a community" and urged them to "strengthen those forces in the community which help to preserve not only our physical well being, but our spiritual health as well."^[76]

Official admiration for the new chemotherapy was thus linked to warnings that the "real" causes of disease were unsolved. Even those most committed to the bacteriological view of disease seemed uneasy about the decoupling of venereal disease from sin and promiscuity: How would sexual morality be controlled if not by the fear of disease? Would "rampant promiscuity" defeat the best efforts of medical treatment?

A brief review of health statistics in the years since the discovery of penicillin suggests that syphilis has, in the main, been effectively controlled. New cases of syphilis are reported each year, and doubtless others are unreported, but the rates are relatively low. In 1986 a total of 373 cases of primary, secondary, and early latent cases were reported in Baltimore; in 1987, a total of 364 cases. Although these cases are of continuing concern to health department officials, at least from the per-

spective of the 1930s and 1940s, the miracle of control really has occurred. Gonorrhea, however, is another story. Gonorrhea continues to be the most frequently reported infectious disease in the United States, in Maryland, and in Baltimore City; as press reports like to say, in numbers of cases, it is second only to the common cold.^[77] But gonorrhea, too, is declining. In 1980 there were eighteen thousand cases in Baltimore, in 1986, sixteen thousand cases, and in 1987, thirteen thousand cases. In 1986, Baltimore ranked second in numbers of cases of gonorrhea among cities with populations of more than 200,000.

Although gonorrhea is of epidemic proportions, it creates little popular concern. A remarkable effort in 1976 to form a coalition in Baltimore against venereal disease—composed of the Boy Scouts, the National Organization for Women, the League of Women Voters, the Benevolent Order of Elks, and the Baltimore Gay Alliance—was unable to fire public interest.^[78] Parents were more concerned about drug use than sex; those infected, or potentially infected, knew the cure was simple, available, and cheap. As Turner had noted, the vital element of fear was missing: Gonorrhea was perceived as an uncomplicated infection, easily treated and readily cured.

As we have since discovered, the fear, and the underlying attitudes toward sexuality, were only lying dormant. The recent public concern, horror, and fear of AIDS have reignited the older social hygiene movement, albeit in a new form. Attitudes once expressed toward the black population as sexually promiscuous, sexually threatening, and a reservoir of disease have now been, in revived form, turned against the gay male population. AIDS is popularly seen as caused by gay promiscuity and, even more broadly, as a punishment for unconventional or unapproved sexual behavior, rather than simply as the result of infection by a microorganism. Just as in the case of syphilis, AIDS is often perceived as the "wages of sin" or, as Jerry Falwell says: "A man reaps what he sows. If he sows seed in the field of his lower nature, he will reap from it a harvest of corruption." Again, the argument pits a new generation of biomedical researchers—eager, in the main, to dissociate a medical problem from a moral crusade—against a new generation of moral reformers, eager to use the new AIDS threat to reform sexual behavior.

The "moral" and "scientific" attitudes toward venereal disease are not, of course, completely separate. As we have seen in the ambivalent responses to the success of penicillin therapy, even the most dedicated scientists tend to share the social and sexual values of their culture—in this case, expressing some regret or misgiving, lest effective and safe

chemotherapy act as an encouragement to disapproved sexual activity by removing the fear of disease. Moral reformers know that scientific successes, especially in the form of new "miracle drugs," will weaken, but not destroy, their case. If a new "miracle drug" is discovered to be effective against AIDS, it will weaken, but certainly not destroy, their social, moral, and cultural objections to homosexuality.

Both the biomedical and moral perspectives or attitudes toward venereal disease select out specific aspects of a complex social reality. As the history of public health demonstrates, venereal diseases—as all other diseases—occur in a social context within which disease is perceived, experienced, and reproduced. One realm comprises both "biological" and "social" aspects of disease. We may separate out one or the other for purposes of analysis, but any complete understanding of a disease problem must involve both as interrelated parts of a single social reality.

Social and cultural ideas or ideologies provide a variety of ways in which diseases can be perceived and interpreted. The germ theory provides an explanation of disease that largely, but not completely, isolates it from this social context, robbing it of some of its social (in this case, moral) meaning. But the purely "scientific" interpretation is never wholly victorious, for social and cultural meanings of disease reassert themselves in the interstices of science and prove their power whenever the biomedical sciences fail to completely cure or solve the problem. Only when a disease condition is completely abolished do social and cultural meanings cease to be relevant to the experience and perception of human illness.