Epidemics and History: Ecological Perspectives and Social Responses

Guenter B. Risse

Current discussions concerning the AIDS epidemic contain references about its possible African origin and hypotheses regarding the introduction and spread of the disease in the United States. It seems plausible to postulate that a set of biological factors, perhaps a viral mutation, had to find a favorable ecological niche—made possible by new attitudes toward homosexuality and widespread drug abuse—to trigger the appearance of AIDS. At the same time, our social reaction to the epidemic, presently undergoing painful reexamination, needs to be considered carefully. Why do sufferers of disease have to be stigmatized? What is all that moral judging for? Voices urge that AIDS cease to be a civil rights problem and become instead a public health issue. The implicit message to the authorities is quite simple: cease quibbling about civil liberties and start protecting public health even if it means returning to previous measures of screening, reporting, and isolation deemed successful in controlling other diseases. How can history help us understand AIDS?

To study past and present disease patterns, including AIDS, we need to employ an ecological model that allows us to discover and integrate the multiple factors involved in the arrival of epidemic disease. The dynamic relationship between the biosocial environment and humans—an "ecology" of disease—helps explain the appearance, spread, and departure of specific health problems.^[1] As we establish certain webs of causality, attention inevitably focuses on the cultural environment and how human activities before and after the emergence of epidemics pre-

dispose or inhibit such dreadful events. History can furnish a valuable perspective from which to view our present predicaments.

The first task of historians is to discover reasons for the shifts that have occurred in the ecology of disease over time, allowing the emergence of successive epidemics of plague, syphilis, smallpox, yellow fever, cholera, polio, and influenza. What biological and social factors could have been responsible for such diseases? Second, we need to examine how past societies have coped with the problem of pervasive disease. What belief systems, institutions, and strategies did they develop when faced with such threats? How did such ideas and actions affect both the healthy and sick?

In order to highlight such ecological and social issues, I have eschewed the frequently employed "panoramic" view, because in my opinion each epidemic—including AIDS—presents a unique blend of ecological circumstances and social responses that develop within highly specific political, economic, and cultural contexts. Instead, I have selected three past epidemics in order to better present the relevant ecological questions and discuss in more detail human reactions to mass sickness.

Plague

The first case study is the final outbreak of bubonic plague among the inhabitants of Rome, which occurred in 1656. For a variety of political reasons—not least the vanity of the reigning pope—this episode was well-documented.^[2] The epidemic was fought with measures developed during the Renaissance, refined over nearly two centuries of organized responses to plague in cities of northern Italy. These measures were widely adopted elsewhere in Europe and in the ensuing centuries became the prototype for public health regulations regarding other diseases, notably yellow fever and cholera.

Although contemporary observers had detected a gradual decrease in the frequency and intensity of plague epidemics in Western Europe, authorities of the Papal States, which included Rome, were nevertheless carefully monitoring the health situation in the Mediterranean. This watch focused especially on the movement of potentially infected ships and their supposedly lethal cargoes. One may ask why the plague was retreating in the face of growing urbanization and increased commercial contacts among nations. Was public health policy on epidemics gradu-

ally bearing fruit? Probably not. The quarantine system simply stemmed the flow of goods, humans, and ships, only indirectly hampering the movement of the real culprits, namely, infected rodents and their fleas. In fact, the regular recurrence of plague epidemics after 1349 owed more to contacts between urban rodents and their increasingly plague-ridden cousins in the countryside than to the movements of ships with their contaminated cargoes. Today we know that, in spite of millions of human victims, plague remained foremost a disease of rodents.^[3]

Significant environmental transformations in seventeenth-century Europe were also affecting the ecology of plague. One of the most critical changes was the gradual separation of urban centers from the surrounding reservoirs of plague-infected rural rodents. Such transformations included deforestation because of preindustrial demands for wood, draining the marshlands, and increasing the acreage under plow; all were designed to feed and shelter the population. These activities unwittingly managed to destroy wild rodent habitats, interposing agricultural cultivation between the teeming urban rat populations and their rural cousins. Even the more mobile brown Norwegian rat, capable of transcending the clearings, was unable to rekindle a decimated rodent population, which indirectly affected humans.^[4]

By the mid-seventeenth century, however, bubonic plague was again spreading from North Africa to Spain and southern France. It arrived in Sardinia, then under Spanish control, in 1652. In spite of trade barriers against the island, the plague smoldered for four years, erupting in Naples in 1656, eventually killing an estimated 100,000 people in that city—about a third of the entire population.^[5] Unfortunately for Rome, the Kingdom of Naples supplied grain shipments to the holy city as part of a feudal tribute. These imports were particularly welcome in view of the poor harvests that year in regions throughout Italy.

Knowing of Naples' serious epidemic, Roman officials in the spring of 1656 began to patrol the border, making careful inspections of all incoming ships, looking for sick crewmen and travelers. In spite of such precautions, however, a Neapolitan fisherman from the Roman port of Ripa—the destination port of all grain shipments—fell ill on May 10 in a rooming house in the Trastevere district of the city, a slum across the Tiber River. Although suspected of suffering from bubonic plague, the man and his landlady denied or pretended to ignore its true nature until she herself and her family came down with the disease. The fisherman was then sent to a nearby hospital, where he soon died of the plague.

His demise prompted an official report announcing the presence of the plague in Trastevere.^[6] Within days, new cases appeared in the adjacent Jewish ghetto as well as in numerous other parts of the city.

According to the Easter census of 1656 Rome had a population of 120,695. In the ensuing months, the city suffered approximately ten thousand deaths directly attributable to the plague. This mortality rate reflects a lower incidence of disease than, for example, reported by the city of London nine years later, where 80,000 people perished out of a total population of 500,000. The discrepancies are difficult to explain, although it is possible that Rome's death rate was underreported because the city's 1657 census counted only 100,119 inhabitants.^[7] Perhaps Rome's rat population, in frequent contact with wild rodents in the adjoining, depopulated marshes, was already partially resistant to plague.

In any event, Rome was a densely crowded city still confined within its medieval walls. Its streets were a disorderly jumble, blocked by stalls with a variety of vendors and by slow-moving carriages. Few inhabitants obeyed the municipal instructions to deposit their rubbish at the appointed heaps along the banks of the Tiber River; most garbage was simply thrown into the streets. "What's the use of living in the grandeur of Rome," wrote one critic, "if one is to walk like beasts rather than human beings. . . . Raise, Holy Father, the poor from the excrement."^[8] A busy Congregazione della Strada—the department charged with the cleaning, repair, and improvement of the city's lanes—fought a losing battle, bedeviled by traffic congestion, lack of parking, and after each sweeping, the inevitable recurrence of garbage.

As in other cities, the poor bore the brunt of crowding and lack of hygiene. Their slums were located in humid, low-lying areas of the city that were periodically flooded by the Tiber, and most of their houses were in advanced stages of decrepitude, with holes in the walls and roofs and "nests of spiders, mice, scorpions and geckoes." Rents were exorbitant and people were forced to live in "cubicles, garrets and holes in the wall"; others were homeless, begging on streets, engulfed in the stench from rotting garbage and animal and human excrement. "Good Shepherd," complained the same critic, "by your leave, we no longer live in Rome but in a pigsty."^[9]

The city was ruled by Fabio Chigi, or Alexander VII, a native of Siena elected pope the previous year. Alexander's passion was architecture on a grand scale. His stated goal was the restoration of Rome to its previous splendor through the completion, renovation, and construction of piazzas, palaces, and churches. With a highly developed sense of public

relations, the pope tried to give the city an image of ample squares, long open streets, attractive buildings, decorative fountains, and renovated monuments. The new look was designed to bolster his personal popularity as well as to attract foreign visitors to a city that had long lost its political importance and was still feared for an insalubrious climate associated with endemic malaria in the surrounding countryside.^[10]

Thus, the 1656 outbreak of plague in Rome could not have come at a less opportune time for the pope. Nevertheless, Alexander VII immediately contacted the Congregation of Health, a municipal bureaucracy created in 1630 by Pope Urban VII to monitor and fight disease. Its leader, the prefect cardinal Giulio Sacchetti, counted in turn on the assistance of another cardinal, Francesco Barbarini, who had successfully organized public health measures against the plague in Bologna twenty years earlier. For the next few months, the group met daily and implemented a traditional series of regulations.^[11]

Following the fisherman's death, the health authorities ordered the immediate suspension of trade with Naples and the Campagna region surrounding Rome. Most city gates were closed, and military guards were posted at all entrances. Temporary stockades were erected in front of gates and remained only partially open to the movement of goods and people; health certificates were demanded from those trying to enter. Jews had to present a special passport. Money and mail were fumigated, and goods and animals placed in quarantine.^[12] At two gates, authorized supplies of grain and wine were transferred through pipes across the fences. Large chains were placed across the Tiber to block all ship traffic to Ripa. Trastevere and the Jewish ghetto, districts where the plague found its first victims, were sealed off and patrolled by guards.^[13]

Having secured Rome's borders, the authorities went on to issue a set of rules to deal with plague inside the city. Traffic was severely restricted, and the streets were cleaned of filth and garbage. Schools were closed. City functions attracting crowds such as markets, parades, and religious processions were altogether banned. Indulgences were offered for people praying at home each night while the church bells rang. Prostitution was officially quashed, and vendors, beggars, and otherwise idle folk were put to work on Alexander VII's construction projects. Many of them were marched off to pesthouses opened for people suspected of harboring the plague.

Police were also prominently involved in the handling of individual victims. Suspected cases reported by relatives or physicians were brought to a number of first-line lazzarettos (quarantine hospitals) for screening.

If clinical signs of plague appeared, the sick were quickly sent on with an escort of soldiers to the larger pesthouse on the island of St. Bartholomeo. Their homes were immediately sealed off by officials; large signs reading "SANITA" (Sanitary Service) were nailed across doors and windows. Surviving relatives could not leave the building under threat of death, remaining there quarantined for several weeks until they could prove their lack of infection.^[14]

After usual periods of isolation, buildings that had housed plague victims could be "purged" of the disease through fumigation. Cleansing smoke came from burning sulfur as well as logs of pine, juniper, and laurel. Cleaners dressed in special vests, their faces covered with sponges soaked in vinegar, entered the contaminated premises and hauled out the furniture and other belongings. Some items were promptly fumigated on the spot through placement on racks while the clothing was sent to special laundries set up in nearby monasteries. Some establishments cleaned the woolens, others the linens. Before the belongings were taken away, elaborate inventories of removed household goods were taken in the presence of a notary.^[15]

After recovery, survivors were placed in a convalescent category and transported to another lazzaretto for further recuperation. Following a prudent period of observation there, these asymptomatic people were conveyed to another makeshift quarantine station in a jail before their final release. In turn, the dead were promptly loaded onto wagons or boats and conveyed downriver to St. Paolo's churchyard and adjacent meadows. Here all naked corpses were buried in mass graves, their clothing burned to prevent gravediggers from recycling it and getting infected. Once in the ground, the bodies were covered with lime soaked in vinegar and fresh soil.^[16]

Each ward in the city organized its own local health commission composed of two physicians and a priest. These individuals went from house to house, the doctors checking for disease while the priest held confessions and administered last rites. They were all considered tainted because of their contact with plague victims and were thus forced to live in isolation during the epidemic. On their appointed rounds, these men were forced to display wooden crosses, a sign of their contamination. Other doctors worked in the lazzarettos. In the course of these duties many of them contracted plague and died.^[17]

The epidemic of 1656 unquestionably caused a great deal of fear and panic in the population. Many inhabitants, including physicians, immediately fled the city, while others simply denied the existence of the dis-

ease. After the slum of Trastevere was cordoned off by authorities, its impoverished inhabitants complained bitterly about the enforced isolation, which took away their livelihood and "freedom of action from all." Although the pope and a deputy—his brother, Mario Chigi—repeatedly crisscrossed the city handing out money to the needy and especially the shut-ins, complaints about these "guardians" (military guards) only increased, as if "the remedy was the true illness," not the plague.^[18] Others were angry with physicians who took advantage of the panic to peddle profitable prescriptions.

In turn, "many sick carried illness without revealing it, hoping to cure the pestilential lungs secretly."^[19] Causes given for such lack of reporting were fear of job loss, terror of being severely punished for disobeying quarantine laws, and just plain embarrassment among the well-off, who refused to confess their defilement by a disease usually associated with poverty and filth. Individuals considered tainted through contact with plague victims, and thus guilty of breaking the law, were shot.^[20]

Most seventeenth-century public health measures were rooted in the widespread lay and medical belief that filth and organic decay generated poisonous vapors that contaminated the urban atmosphere. Floating in the form of invisible particles, these vapors were thought to either penetrate the skin or be inhaled; occasionally they passed from one person to another as contagion. Once in the body, such matter could disturb the victim's humoral balance, but only if his or her constitution was already compromised and thus predisposed to illness.^[21]

Based on such a system of explanations, most public health measures focused on two objectives: eliminating the sources of poisoned air, or miasma, and keeping the healthy away from the sick. Environmental cleanups and quarantines, trade bans, and isolation of suspected victims were the central aims. Representing the values and concerns of a healthy elite, the public health authorities took an energetic and heavy-handed approach to protect its long-term political and commercial interests. Privacy was invaded, suspects forcibly removed from their homes, lists of victims published, houses closed, relatives shut in, beggars expelled. Violators of public health regulations were fined, summarily executed by firing squads, or hanged from gallows erected in piazzas around the city. Those committing serious crimes were actually torn apart, and their limbs publicly displayed. Informers usually received a third of the levied penalties.^[22]

Scapegoats were easily found. First, of course, there were the foreigners, especially those who had arrived from plague-ridden Naples

and could therefore be blamed for introducing the disease. The first victim was thought to have imported tainted "feminine ornaments—silk ribbons,"^[23] thereby starting the epidemic. As always, there were the Jews, more than four thousand of them, already crowded into an unhealthy and densely populated ghetto less than a square mile in diameter near the Tiber. As a result of their strict confinement, nearly 20 percent of the ghetto inhabitants died during the epidemic.^[24] The poor, who inhabited the slums like the Trastevere district, were also convenient scapegoats. Initially they suppressed information about the presence of plague in their midst out of fear of being quarantined; later they were also less than forthcoming about presenting themselves to the magistrates who were trying to screen them for disease. According to statistics, more than half of Trastevere's three thousand residents died during the epidemic.^[25]

Whether the public health measures actually hampered the progress of the epidemic throughout the city remains questionable. In the Jewish ghetto and Trastevere, however, the quarantines served to facilitate human contact with plague-infected rats, thus significantly increasing morbidity and mortality in those areas. Although the papal authorities tried hard to portray their determination to care for all Romans and to mitigate individual hardships, the powerless, as usual, bore the brunt of the disease. They were the scapegoats, deprived of jobs, food, and adequate shelter, and herded into disease-infested places separated from the rest of the population. The observation of a contemporary that the "judgment of the masses was ungrateful regarding the charity of their rulers"^[26] would indicate that those who suffered most during the epidemic were not very impressed with Alexander VII's public health measures. It was "as if the evil [plague] was imaginary and the cure the real evil," admitted one official.^[27]

Cholera

Less than two hundred years later both Europe and America faced a new disease—cholera—although a number of historians argue that cholera has been around since the sixteenth century. Speculation about its origin continues. A recent hypothesis argues that a relatively harmless water-borne bacterium, easily destroyed by acid in the stomach, mutated in India early in the nineteenth century, suddenly acquiring the ability to produce a powerful toxin responsible for the severe diarrhea and vomiting, resulting in an enormous loss of fluids and high death rates.^[28]

Once launched, cholera spread quickly in successive epidemics affecting virtually every country in the world. Its transmission was possible because of increased and more rapid means of transportation. Moreover, the industrial revolution promoted an accelerated and poorly planned urbanization that frequently allowed the mingling of human wastes with water supplies—ideal conditions for a disease like cholera.^[29]

Reports from West Bengal suggest that the first cholera pandemic originated there in 1817, spreading throughout Asia and East Africa. A second wave began in 1829, quickly moving into Russia (1830), Germany and Britain (1831), and France (1832). Having effortlessly crossed the seas and three continental landmasses, there was a justified fear that cholera would also travel to the New World, given the high volume of transatlantic traffic. Although the demographic effect of cholera's deaths was relatively small compared with the great killers of the past—nevertheless, in Britain alone about thirty thousand people died of the disease in 1831-1832—its sudden evolution and spectacular symptoms caused considerable horror and panic.^[30]

In the spring of 1832, therefore, Americans warily awaited cholera's leap across the Atlantic. Even before cholera broke out in Quebec and Montreal on June 15, New Yorkers had braced themselves for the onslaught by reorganizing the city's sanitation system. Money was made available to erect hospitals should cholera strike.

Although holding infrequent meetings, the city's permanent Board of Health had been in operation since the yellow fever epidemic of 1822.^[31] When cholera erupted in Europe, board members—including New York Mayor Walter Bowne and city aldermen—gathered information about the disease. By the fall of 1831 quarantine regulations went into effect for the screening of all incoming passengers and goods first from Asia and Africa, and then from southern Europe as cholera spread to that continent. By June 1832 a blanket quarantine against all European and Asian travelers went into effect. No vessel could approach within three hundred yards of the docks if suspected of carrying cholera victims. American physicians, in turn, went to Canada to observe the newly arrived disease and returned to issue recommendations for preventing the scourge. Cleanliness and temperance were considered critical.^[32]

New York had a population of about 250,000 at this time. With the greatest port on the continent, the city was a thriving but densely populated commercial center. Thousands of European immigrants—especially the Irish—crowded into the humid, marshy areas of Lower Manhattan, occupying unfinished cellars and back rooms. Located near the

docks and common sewers, these slums furnished a highly favorable ecology for cholera. Horse stables as well as pens for cows and swine dotted the alleys; more than a thousand pigs roamed through the streets. Following the news from Canada about the arrival of cholera, perhaps as many as a hundred thousand inhabitants left the city. Driven by fear, people fled in stagecoaches, steamboats, carts, and even wheelbarrows.^[33]

In spite of all precautions, an Irish immigrant named Fitzgerald became ill on June 26, 1832, complaining of stomach pains. His wife and two children were similarly affected, and although he recovered, they died a few days later. Perhaps there had been previous victims of cholera, hidden from authorities or deliberately unreported by officials to avoid panic. In any event, within days the news circulated that the disease had appeared in various areas of the Lower East Side, and in the notorious "Five Points" area in the Sixth Ward, Greenwich Village, and the Bellevue almshouse. Before it was over in September the epidemic killed nearly 3,500 inhabitants, claiming most of its victims—perhaps 2,000—among the poor.^[34]

On July 2 the Medical Society of New York announced that nine cases of cholera had already occurred, expecting to prod the municipal authorities into greater action.^[35] Although the Board of Health considered the medical declaration an "impertinent interference" in its affairs, members agreed to appoint a special medical council, composed of seven prominent physicians, to look into the matter. Like the Roman Health Congregation, this group promised to meet daily and, if necessary, to issue public health regulations. Predictably, the medical confirmation of cholera in New York merely exacerbated the exodus already in progress. "Oceans of pedestrians" were reported on roads leading out of the city. Farm and countryhouses within a thirty-mile radius quickly filled up with panic-stricken refugees.^[36]

Despite professional opinion that cholera had indeed reached the city, the Board of Health and especially the newspapers continued to question the assertion. Fearful passengers on steamboats landing in New York resented the medical announcement as "injudicious and premature" by "unauthorized and meddling doctors which have filled the nation with such groundless apprehensions."^[37] No matter—the alarm had been sounded. In the eyes of one observer, the Fourth of July holiday lacked the "usual jollification." Stores were closed and the official parade was canceled, although some troops marched on their own and "the places of public amusement were filled in the evening."^[38] Although the Board of Health was forced to report twenty new cases and eleven

deaths for that day, all presumed to be cholera victims, one newspaper tried to soften the impact of such tidings by explaining that festivities associated with national holidays caused fatigue and notoriously encouraged intemperance in eating and drinking. Only such preconditions, it suggested, would allow the appearance of the disease if combined with environmental pollution.^[39]

Over the next few weeks the press tried to minimize the importance of the epidemic. The Board of Health required that practitioners who were reporting cases also disclose the sex, age, occupation, and former health of their patients. It not only published daily the names and addresses of new cholera victims but also the number of individuals brought to the various city hospitals suspected of having the disease. In addition, the board now included on its lists the names of the doctors reporting the cases. Reporters quickly realized that most attending physicians reporting cholera cases were not among the professional elite then practicing in the city, many of whom had obviously left with their rich clients; this created further skepticism about the seriousness of the cholera epidemic. "The alleged visitation of the Asiatic cholera seems to have brought an entirely new fry of doctors into existence as a shower of summer rains brings out a new race of frogs and toads," mused one paper.^[40] The unknown doctors could not be entirely trusted, the paper suggested, to provide an accurate picture of morbidity. "We have some cholera in the city," concluded the article, "and a great deal of humbug."^[41]

Although not among the elite, the physicians who cared for cholera patients took considerable risks. Theirs may not have been household names gracing the social pages, but these practitioners "who pass[ed] swiftly up and down the streets in their gigs" tried to find early cases of the disease when in their eyes treatment still had a chance to succeed. By contrast, prominent members of the medical profession who were advising the Board of Health expressed "fear of contagion," and in fact dared "not to enter the room in which a patient lies suffering from that affection which these very medical advisors deny to exist."^[42]

Errors in reporting by the Board of Health continued to generate skepticism about the true impact of cholera. Alarmed neighbors found one presumed victim busily engaged over her washtub; a barber in the Bowery was quietly shaving customers when the newspaper announcing his illness was thrown through his doorway.^[43] In any event, the lists chiefly disclosed "the intemperate, the dissolute, and the poor creatures who are too ignorant to know what to do, or too destitute to procure

needful attention."^[44] Because most casualties indeed occurred among marginal members of society, the "causes of apprehension" concerning cholera were, according to press reports, "greatly diminished." Perhaps because of this, the authorities were slow to promote the usual public health measures. "What in the name of common sense is the reason the Corporation will not do their duty?" someone wrote in the physicians' Cholera Bulletin of July 13.^[45] Indifference to the citizens' welfare was the charge; the officials were told to resign. In an utterance reminiscent of contemporary statements on AIDS, the same author wrote: "Public health is now at stake, and if prompt and efficient measures be not immediately adopted to secure it, in a short time it will be too late, for thousands of our citizens will have been consigned to the tomb."^[46]

Finally, time-honored public health measures were indeed implemented, including a vigorous campaign of street cleaning. Instead of merely dampening the refuse with water, workers actually deprived many streets of knee-high manure, garbage, and dead animals—only to dump it, however, on other city roads. Cesspools were covered with quicklime, and "nuisances" around slaughterhouses were discarded. Houses that had harbored the sick were fumigated and purified using chloride of lime and sulphuric acid. Walls were whitewashed. Fire destroyed clothing and bedding belonging to cholera victims. Tar and pitch were burned to purify the atmosphere. "Let us learn from the past," stated the Cholera Bulletin , "and by improving the present, diminish the danger to the future."^[47]

As one resident of Five Points—that "hotbed of contagion"—complained, such public health measures were not equally enforced in all areas of the city. In that neighborhood, rubbish continued to be thrown into the streets with impunity. At night, beds and bedding belonging to cholera victims were also burned outside. Hemmed into a crowded ward that now reported thirty to forty cases of the disease daily, residents produced enough refuse at Five Points "to feed the cholera for the next forty years." Not even the Fire Department dared send their trucks there. Referring to the slumdwellers at Five Points, one critic felt that unless some action by the authorities was forthcoming, "at the end of that time (forty years) there will be no occasion for their interference."^[48] In a word, it was hoped that, if left sufficiently alone, the susceptibles would all die and the disease would burn itself out.

Instead of neglect, others advocated harsh measures. "The Five Points and their vicinity are inhabited by a race of beings of all colors, ages, sexes and nations, though generally of but one condition, and that be-

neath the nature almost of the vilest brute," wrote one reader.^[49] The cure was easy: "Turn out the inmates of the place, ventilate and purify the beastly hovels, guard effectively against their return, fence up the streets."^[50] In certain instances compulsory evacuation of the poor to makeshift shanties was actually carried out.

In the meantime, New Yorkers witnessed a rampage of vandalism in dwellings belonging to those who had left the city. Carpets were cut to pieces and furniture broken; some homes were completely ransacked from top to bottom. Lacking a sufficient security force, the authorities seemed unable to control the crime wave. In response, many homeowners quickly procured insurance against theft. "At the present crisis, those who are leaving town would find it a measure of prudence to effect an insurance," advised the New York Equitable Insurance Company.^[51]

Those suspected of harboring cholera were quickly taken to makeshift hospitals for observation and treatment. Because the Medical Council had concluded that "the disease in the city is confined to the imprudent, the intemperate, and to those who injure themselves by taking improper medicines,"^[52] hospitals classified their admissions "according to habit" into "temperate" and "intemperate," with an intermediate category of "irregular"; unconscious or dying patients were termed "uncertain."^[53] Drunks were often reported as cholera patients. The dead were buried with indecent haste in mass graves dug at Potter's Field, robbing families of traditional wake practices. Instances of resistance to such public health measures were reported, with angry mobs attacking and beating up city officials and even some physicians.

The practices described above reflected the widely held belief in the atmospheric origin of the disease.^[54] Because of cholera's erratic epidemiological patterns, the issue of direct contagion was frequently debated but generally deemphasized. In spite of repeated pronouncements that they were useless and bad for business, traditional quarantines continued to be imposed by apprehensive officials. Poisonous particles from urban decay were thought to rise from streets, cellars, and tenement houses. Such vapors were presumed to irritate both stomach and bowels but led to cholera only if the individual's constitution was already weak because of dietary deficiencies and excessive consumption of alcohol. Cholera and rum traveled together: "Short is the transition from the grog-shop to the hospital, to the grave, and to perdition."^[55] Critics questioned such medical assumptions, pointing out that cholera cases frequently appeared in almshouses and jails where no liquor was available.

Indeed, the association of cholera and intemperance filled the pages of medical books, pamphlets, handbills, and newspapers. "It is now universally known that cholera has a most peculiar affinity for the system of a drunkard, so much so that it is a very rare thing for the intemperate to escape," wrote one physician.^[56] "Well-appointed nurses" at hospitals were instructed to obtain a "correct" history from newcomers regarding their drinking habits. Even small amounts of port, brandy and water, or wine taken as cholera preventives were considered harmful.^[57] Taverns ("abominable styes of pollution") and liquor stores ("visible nuclei around which the epidemic raged with unwonted fury") were especially singled out as sources for a habit that now could lead to the dread infection. Cholera victims were perceived to include "the poorest class of Irish, many of them have for years (as they themselves confessed) been almost daily intoxicated."^[58]

Not coincidentally, cholera claimed most of its victims among New York's poor, those who received the lowest wages but were forced to pay high rents for the humid and filthy cellars they called home. Among the women, there were poor seamstresses driven into prostitution, their susceptibility to the disease explained by the combination of "filth, crowded rooms, irregular diet, intemperance, and the debasing vice to which they are addicted."^[59] Others were "hard-working women whose constitutions had been broken by years of incessant toil."^[60] When cholera broke out among "carefully conducted" middle-class people, however, physicians were perplexed. In one boardinghouse on Broad Street, stumped public health inspectors pondered the death of the respectable owner and her daughter. Finally, a "local mischief" was found: a large quantity of cattlehides and bones rotting in the cellar of an adjacent warehouse.^[61]

In the eyes of most contemporaries these were "innocent" victims of cholera. Most were thought to have willfully weakened their bodies through unwholesome ways of life and were now being punished for their sins. According to religious leaders, the three prominent abominations of the time were sabbath-breaking, intemperance, and debauchery, and cholera was viewed as a disease of "mental and corporeal debility."^[62] The best preventive measure was a prudent life emphasizing temperance in eating and drinking, avoidance of garden vegetables and fruits, abstention from ardent spirits, and sexual moderation.

Among practitioners there was pessimism regarding compliance among the poor. "The mass of mankind are, and there is reason to fear,

ever will be insensible to the operation of great moral principles," wrote one physician.^[63] Cholera was therefore viewed as a just punishment for people who were unwilling to change their lives. For many contemporary observers cholera was a godsend: It gave the temperance movement a formidable impulse by exposing the danger of ardent spirits. Providence had brought "good out of evil" and taught a valuable lesson to civil and municipal authorities. The sacrifice of cholera victims had not been in vain!

By the end of July the worst seemed over. The number of reported cholera cases was down, ostensibly unrelated to public health measures.^[64] With all the accusations of intemperance and vice in relation to cholera, criticisms were voiced about the role of "newsmongers," writers, and even newspaper readers who were accused of prolonging the terror. The press was blamed for displaying an "unruly passion for publishing this heaping of trifling matters" in response to demands by eager consumers of print, who became confused "from such a heterogenous assemblage" in blanket size, as they "devoured [it] in a constant panic."^[65]

Medical professionals raised another issue: the official reporting of cases by the Board of Health. Indisposed patients reported by their attending physician could be listed twice if any of them got admitted to a hospital and appeared the next day among hospital cases. If the victim died, there was the possibility of being listed a third time. "Is this not humbugging the public and most unjustifiably magnifying our distresses?" asked one practitioner.^[66] To make matters worse, the Health Board apparently never checked the truth of such reports, although physicians providing incorrect information could be fined. Because of the suspected and proved inaccuracies in reporting the epidemic, the public at large remained ambivalent about the seriousness of the epidemic, an uncertainty not conducive to allaying their fears.

By August 27 thousands of refugees returned to New York City in spite of warnings by the Special Medical Council that the streets and city air were still polluted. Those coming back were invited to "contribute in preserving the commercial and trading interests from destruction."^[67] Among them were physicians "who, impelled by the desire of avoiding the unprofitable labours which such calamities impose on our profession, deserted their posts in time of danger or sought refuge from their personal fears by inglorious flight."^[68] Devoid of patients, some of the cholera hospitals closed their doors. As one contemporary observed, "business has revived, the streets are lively and animated, and every-

thing seems to be resuming its wonted appearance."^[69] The sky, clear because of idle factories and unused domestic fireplaces, gave way again to "the dense cloud of smoke which always lays over the city."^[70]

As in the previous case of plague, the cholera epidemic of 1832 constitutes another paradigm for social responses to disease. Here again, the poor—often immigrants—were the primary victims both of the disease and of the blame. In this view, moral failings thought to be responsible for poverty and dissipation provided a fertile substratum for cholera to break out among those marginal sectors of society "different" from the hard-working, God-fearing majority. Public health measures sought to clean up the environment, thus reassuring the anxious public, but the activities were selective: Slums such as the Five Points area continued to wallow in garbage and to be without fire protection. Epidemic disease served once more as a focus for the expression of religious, political, and cultural biases within society.

Polio

The third and final case study presented in this chapter deals with the serious epidemic of poliomyelitis, or infantile paralysis, which erupted among inhabitants of New York City in the year 1916. The disease had been rare before 1907, although minor episodes occurred in Austria (1898) and Scandinavia (Norway and Sweden, 1904). In Rutland, Vermont, an outbreak of polio was reported in 1894 which took the lives of 132 people before striking New York in 1907 and killing an estimated 2,500 persons. After 1907 polio epidemics became increasingly more frequent. Between 1910 and 1914 alone about five thousand deaths and thirty thousand cases were reported in the United States.^[71]

As in previous instances, human actions contributed decisively to the creation of a favorable ecological setting for poliomyelitis. Ironically, the culprits were improved public sanitation and personal hygiene, slowly achieved after decades of cholera and typhoid fever. Such relative cleanliness presumably reduced the transmission of wild and ubiquitous polioviruses that had hitherto routinely infected most infants and young children without producing paralytic complications. As a consequence, these groups became increasingly unprotected and susceptible to the crippling form of disease. In fact, many children became polio victims soon after being weaned and thus deprived of maternal immunity.^[72]

Ever since poliomyelitis had become a reportable disease in 1910,

public health authorities everywhere carefully monitored its appearance. This was especially true during the summer months, when polio was known to strike. Authorities in New York were especially on alert because the city had already suffered two serious epidemics of the disease in 1907 and 1910. The new administration of Mayor John P. Mitchell was proud of its Health Department. This unit was composed of competent professionals and led by Haven Emerson, a former medical practitioner who had treated the last cases of cholera. Successful campaigns against unsanitary boarding rooms, subway and streetcar crowding, as well as trade in patent medicines had bolstered the department's morale. In the eyes of its officials, a declining infant mortality rate testified to the city's sanitary standing. Its combined population from all five boroughs was estimated at 5,570,000.^[73]

All but forgotten in the midst of an election year, the war in Europe, and a Mexican-American crisis prompted by Pancho Villa's raid, the first cases of polio in New York were reported on June 6. All of the sick children came from a densely populated section of Brooklyn near the waterfront, primarily populated by Italians. Visiting nurses making a house-to-house search soon discovered another twenty-two victims of the disease, some ill for several weeks but not severely enough to demand medical attention.^[74]

There was no denying it. Polio had returned to New York. In the following days 327 new cases were disclosed in Brooklyn alone, with a mortality rate of about 20 percent. Before it was all over in November, New York City reported a total of 8,927 true cases of polio and 2,343 deaths, with the two less-populous boroughs, Richmond and Queens, actually showing the highest case rates. Nearly half of the victims—4,500, were seen in or admitted to the city's hospitals. Nationwide, the poliomyelitis epidemic of 1916 affected 27,000 people in 26 states and caused about 6,000 deaths.^[75]

One of the first tasks of the New York Health Department was to ascertain the dimensions and geographic contours of the new epidemic, a coordinated process based on numerous field reports provided by an army of inspectors and nurses. As one publication stated: "It is the health officer's task in an epidemic to know where all cases are in his bailiwick."^[76] Detection and disclosure of new cases was paramount to achieving control of the epidemic, and it could only be carried out with the help of the medical profession and the public. Neighborhood health stations were at the forefront of these search-and-report missions. Some infants brought in for regular visits could not hold on to their bottles.

Mothers were advised to bring all febrile children, especially those with "weak legs" or to send for a doctor.^[77] All physicians in affected areas were urged to cooperate. Moreover, the authorities offered diagnostic lumbar punctures and spinal fluid examinations free of charge.

As the house-to-house searches were stepped up with the help of additional inspectors and nurses, quarantine procedures went into effect to isolate the suspected victims of polio.^[78] Many children were promptly and forcibly separated from their parents and removed to specially outfitted pavilions at nearby hospitals for proper diagnosis and treatment. Initially, most patients arrived at Kingston Avenue and Queensboro hospitals.^[79] Only two visits to the sick by members of the family were allowed over the next eight weeks. Confirmed cases of the disease were made public, and their names as well as addresses were published daily in the newspapers. Parents were urged to read the lists and keep their children far away from the infected places. Houses yielding victims of the disease were immediately placarded. Like a scarlet letter, the clearly visible sign was placed outside on the street front and in tenement buildings on the street door, entrance hall, and apartment door. Inspectors checked on the yellow signs daily, trying to discourage their removal, which was subject to a heavy fine.^[80]

Well-off parents, of course, could keep their sick children if they could provide them with a separate room and adequate nursing as well as medical care. Such isolation lasted eight weeks and required comprehensive cleaning of the premises, provision of separate bedding and utensils, and careful disposal of bodily discharges. If a child died at home, coffins were immediately sealed and burial occurred without a church ceremony. Houses were thoroughly fumigated and new wallpaper installed. All surviving siblings under the age of sixteen were quarantined in the house for the next two weeks.^[81]

To ensure public support for such draconian isolation measures, Haven Emerson and his Health Department prepared half a million yellow leaflets for distribution. New Yorkers were told that polio was "a catching disease," its method of spread "not yet definitely known." Its germ was present in discharges from the nose, throat, and bowels of ill and even healthy persons, and therefore it was essential for children to stay away from crowds in parks, swimming pools, movie houses, and stores. Fresh air, wholesome food, shower baths, and general cleanliness were recommended as the best prophylaxis.^[82]

The role of filth in poliomyelitis and its implications for public and personal hygiene was ambiguous but attractive to public health officials.

Because the spread of the disease was unpredictable—ignoring class distinctions and geographical boundaries—the idea of an environmental factor responsible for transmission of the disease was quite appealing. Moreover, experiments carried out in 1912 by Milton Rosenau, a professor of preventive medicine at Harvard, suggested that flies, especially the biting stable fly, could transmit polio. Although the importance of this possible vector was still under investigation, the Health Department could not ignore it.^[83] All scientific studies concerning infantile paralysis were problematic at this time. Although a virus believed responsible for the disease had already been isolated in 1909, virology was still in its infancy; given the contemporary climate of fear, no one could take any chances.^[84]

The New York Health Department therefore embarked on a vigorous cleaning campaign. Four million gallons of water were dumped daily on the city's streets, paradoxically before the garbage was hauled away. Refuse and ash piles accumulating in halls of tenement houses and on sidewalks had to be removed. All stray cats and dogs were collected; according to the Society for the Prevention of Cruelty to Animals, three hundred to four hundred fifty cats and dogs were put to death daily in early July. Flyswatters and screens to fend off the gregarious stable fly and its less aggressive domestic cousin were widely dispensed. Parents were urged to keep their homes spotless, and to go over all woodwork daily with a damp cloth, sprinkling floors with damp tea leaves or shredded newspaper before sweeping; to take daily baths; and of course, to keep covers over each garbage pail.^[85]

Homeowners caught depositing refuse on the streets were fined. Brooklyn, an early locus of the epidemic, became the black sheep in the eyes of Commissioner Emerson. He accused its citizens of lacking enough civil pride to keep their streets clean, suggesting that perhaps they were responsible for the abundance of cases there.^[86] An army of thousands of volunteers began patrolling the neighborhoods on foot and on motorcycles, checking for violations of the Sanitary Code. By July 11 the authorities had already charged 148 individuals with violations; eventually 2,266 such summonses were listed.^[87]

As most public health measures increasingly focused on environmental filth and garbage, polio began to be viewed as another plague of poverty primarily affecting the same marginal slumdwellers who had been blamed for previous epidemics. "If we could get rid of ignorance and the filth and superstition that go with it, there would be little need to hunt down the mysterious germs that no filter can stop and no microscope

disclose," wrote one editorialist.^[88] Indeed, the poor lacked the airy, clean, and cheerful rooms which Emerson recommended for the domestic treatment of polio cases. They seemed unable or even resistant to following the rules of hygiene which presumably contributed to a disease-free environment. "Defilers of the streets are to blame," commented one writer.^[89] Even New York's mayor stressed cleanliness. "There is no occasion for alarm or panic," read Mitchell's statement published July 9 "Careful observance of the simple directions given by the Health Department as to personal and household cleanliness will go far to prevent further spread of or exposure to infection."^[90]

Not surprisingly, poor Italian families bearing the early brunt of the epidemic were suspected of having introduced polio from their homeland, although inquiries by Emerson to the quarantine station at Ellis Island failed to confirm such an impression. Both the immigration authorities and American consular staff in Italy declared that no polio cases had been reported in that country. In spite of such reassurances, suspicion lingered and quickly included Lower East Side Jews and Poles, who also furnished a disproportionate number of polio cases. Certain neighborhoods appeared to be especially dangerous. One of them was "Pigtown," an Italian section of Brooklyn around Albany Avenue and Maple Street.^[91]

As the toll from the epidemic mounted in July, the New York Health Department increased its "war" against the crippling scourge. Among the newly recruited "forces" were 21,000 citizens organized by the city's police commissioner under the banner of "Home Defense League." Its members spread out to every precinct, where they worked thirteen-hour shifts accompanying policemen on patrol and searching for violations of the sanitary code. Grocery stores, fruit markets, and street vendors came under strict surveillance. One hundred and fifty gangs with water trucks were placed into service. All theaters and movie houses were closed to children under the age of sixteen.^[92]

Public acceptance of and cooperation with such a health campaign were critical, and Emerson was quite aware of the difficulties awaiting him if he failed to persuade the community through educational means about the importance of sanitary and quarantine measures. "Anything which causes antagonism of the public to the policy of reporting and removal to isolation hospitals, develops deception, hiding of cases, and such methods of obstruction as to frustrate to a great degree any approach to successful separation of the sick from the well."^[93] But how could the public be convinced? Repeated visits by public health nurses

trying to educate families at risk proved only partially successful. The pitch was directed to the children of immigrants themselves, who apparently grasped the importance of the measures before their parents; because of cultural and language barriers, these parents were less amenable to the sanitary gospel. "Results obtained among adults were largely due to fear of authority and the force of the department and not to voluntary action on their part," commented one newspaper editorial.^[94]

There was, of course, resistance to the actions of the Health Department. As the seemingly conflicting messages of environmental hygiene and personal contagion took hold, fear began to grip the wary. "Many a family of children was housed for weeks, often in tight-shut rooms, the children's pale faces pressed against the window panes, mute evidence of their unreasonable imprisonment," recalled Emerson.^[95] Others slammed the door in the faces of visiting nurses, who were suspected of carrying polio from one family to another. One nurse stationed at a pediatric clinic in Brooklyn, who had repeatedly reported cases of the disease as well as violations of the sanitary code in "Pigtown," received a life-threatening "black hand" letter and from then on had to be escorted by a policeman between her home and place of work.^[96]

The Red Cross, in turn, provided its nurses for home visits because they apparently generated less fear among mothers who worried that their children would be summarily confiscated and removed to hospitals. The latter were rumored to be hotbeds of polio infection easily transmitted to arriving children and health personnel. Even many private schools and colleges refused to admit students on trivial grounds.^[97]

By mid-July publicity surrounding the polio epidemic in New York City prompted a major effort by neighboring communities and indeed the rest of the nation to confine the city's children within the metropolitan area, thus avoiding a possible spread of the disease to other cities and villages. Towns on Long Island, a favorite summer destination for countless New York families, placed billboards at their city limits urging city dwellers with children to return home. Hotel-owners admitting them overnight were heavily fined. At numerous railroad stations families traveling with children were turned back or placed under observation.^[98]

With assistance from the U.S. Public Health Service, the New York Health Department agreed to issue one-day health certificates or traveler's identification cards, certifying that the child was free of symptoms and did not come from an infected household. The same document could also be obtained from a private physician after an examination.

The certificate was routinely requested from all children under the age of sixteen before embarkation for travel at all ferry and rail terminals as well as steamboat piers. Those who managed to leave without such cards were not allowed to disembark at their destination.^[99]

Although thousands of certificates were issued in the following weeks, many communities around New York City refused to accept them. Some demanded similar documents from the accompanying adults, and other communities, such as those in Connecticut, quickly escorted arriving families out of town and abandoned them in open fields. One child from Brooklyn, who possessed a health certificate, came down with polio in Rochester, forcing Emerson to reiterate that the examination given prior to issuance of a permit card could not detect disease during the early stages of incubation.^[100]

Given the presence of large numbers of healthy carriers, Emerson actually questioned the ban on travel out of New York City. In his view, such quarantine measures were futile and had no effect on the spread of the epidemic. "I know that nothing has developed so many automobile detours, such ingenuity in the violation of the laws, and such wholehearted disrespect for reasonable sanitary law and its enforcement."^[101] Strangely enough, Emerson's opinion about quarantines outside New York was totally at odds with his strong belief in their utility within the city.

Emerson's reference to travel detours was pertinent. Anxious parents planning summer outings or more extended vacations flooded the Automobile Club of America with requests for routing around the more than five hundred quarantines imposed by towns and villages bordering New York City. In many instances guards with red flags were posted at the entrance of such towns, stopping every automobile and carefully searching for concealed children. Those carrying anybody under the age of sixteen had to report to police stations or health offices.^[102] "I hardly need to recall the countless instances of inconvenience, hardship, yes, real brutal inhumanity which resulted from the application of the general quarantine," admitted Emerson.^[103] No wonder so many people "developed a most perverse ingenuity in discovering automobile detours."^[104]

During the month of August, reported cases of polio began to ebb, and doubts were increasingly voiced concerning the success of Emerson's quarantine measures. The vector theory of the stable fly was discredited;"^[105] dissemination of polio was now thought to occur mostly via unrecognized carriers through person-to-person contacts. It was also thought that the decline in polio cases resulted from the depletion of

susceptible children who lacked natural immunity.^[106] "Perhaps twenty-five years from now our present prophylactic efforts may appear to have been too troublesome, over strenuous, or even ill advised," conceded one editorial in a medical journal.^[107] With the epidemic now abating, it was safe to criticize such measures. In nearby Oyster Bay irate fathers interrupted a town council meeting on August 28 demanding the return of their children who had been removed to isolation hospitals. The local quarantine was branded as another instance of "propaganda to terrify the people."^[108]

One cannot avoid noticing a sobering skepticism which overtook public health officers, medical practitioners, and scientists as the polio epidemic of 1916 came to an end. The New York City Health Department had tried in part to control the outbreak by teaching the public everything known about the disease with the help of professional groups, volunteer organizations, the press, and leaflets. After all, responsibility for infectious diseases had significantly shifted in the twentieth century from the environment to individuals, their way of life, and behavior. But public education alone was certainly not enough; it only heightened the fears of many, failed to reach others because of ethnic and social barriers, and, moreover, failed to stem the epidemic.

Emerson was persuaded to adhere to sanitary principles and isolation methods employed since the Renaissance. As he wrote: "Health of the individual is a public asset in which the civil government has an interest and for the protection of which broad police powers may be exercised."^[109] Such functions were specifically authorized by law, then executed and enforced for the public good at the expense of individual rights. Environmental sanitation, quarantines, and isolation of the sick were among the key objectives of such a campaign.

None of the approaches was entirely successful. "As to the lessons we have learned during the epidemic," declared one physician, "we have learned very little that is new about the disease, but much that is old about ourselves."^[110] Scientists were still debating the nature of the agent causing polio and its method of transmission. Physicians, while expressing appreciation for the great clinical opportunities furnished by the epidemic, argued about the usefulness of spinal fluid examinations and convalescents' serum treatments.^[111] Five hundred children with varying forms of paralysis presented formidable challenges to those entrusted with their rehabilitation.

And then there was public health. Isolation and quarantine had appeared to help stem the onslaught of polio. But, did they really, or was

the waning of the epidemic during autumn just part of a natural cycle? No matter. Again ethnic minorities and the powerless poor had been stigmatized in the name of established public health dogma.^[112] "The sanitary code is a body of sanitary law passed by the Board of Health in the last fifty years," asserted Haven Emerson, "it is the substance of the best that the medical profession has been able to produce for the community control of disease."^[113] Residents of Oyster Bay saw it differently. Their resolutions lifting the local quarantine concluded with the statement that "both profane and modern history are replete with the medico-politico barbarism of which we are now receiving a sample as anyone who knows the history of quarantine must understand and acknowledge."^[114]

Conclusion

What are some of the implications of each case study presented in this chapter? Is there anything about these epidemics that could inform our approach to AIDS? Are there "lessons" here we cannot ignore? In the first place, we need to be aware that epidemics are the result of a complex interplay of biological and social factors which at certain points in our history create favorable ecological niches for given diseases to thrive and therefore decimate humankind. As we observed with epidemics of plague, cholera, and polio, the appearance of such illnesses was facilitated by bacterial and viral mutations, voyages and migrations, wars and trade, as well as the development of cities and social classes.

Most of these events were components of an intricate web of causality imperfectly understood even today. As epidemics erupted in history, the contours of such relationships were not only dimly perceived but also frequently completely misunderstood, particularly when the etiological agent remained unknown. Yet it is important for us to review the ecology of past infectious diseases and to reconstruct it as well as possible. Although often speculative, these studies allow us to see the ebb and flow of disease as inevitably complex and even erratic events. Such a perspective may provide encouragement to those who are constructing an epidemiological model for AIDS—an essential step if we are to control the disease.

Perhaps just as important for our understanding of the social dimensions of AIDS are the reviews of previous responses to mass disease. Our public memory has grown dim and we need to remember the social re-

actions to other epidemics, particularly because, with AIDS, we are already repeating them, despite all of our perceived sophistication. Although each disease has its own clinical characteristics, it often targets social groups which are more vulnerable to it because of genetic, cultural, and political factors.

In the face of epidemic disease, mankind has never reacted kindly. Collective fears, anxiety, and panic prompted a number of measures designed to protect the still healthy by cleaning up an environment deemed to be harmful, and by identifying, removing, and isolating those already found to be sick. As we saw in the epidemics discussed above, these rational self-protection measures formed the core of a sanitary code that has been legislated, executed, and enforced for centuries in different societies around the world.

That these sometimes drastic measures emerged at the same time that city states consolidated their political power and established complex bureaucracies to control the economic resources of their respective states is by no means coincidental. Healthy citizens were needed to achieve the goals of state sovereignty and commercial success. Epidemics created emergency conditions in which civil rights were suspended in the name of public survival. As all three case studies demonstrate, freedom of movement, privacy, and confidentiality were rescinded by authorities struggling to control the effects of disease.

Organized responses to epidemics were obviously not totally heartless exercises in power politics or economic self-interest. Health officials often risked their own lives in the implementation of sanitary laws and at times sought to ameliorate the economic impact of quarantines. Given the lack of knowledge about the causes and mechanisms of disease, these measures may have been reassuring to a majority of the population in a climate of panic and fear. As visible testimonies of society's obligations to protect the public health, these rules received broad approval and support.

Finally, we should also remember that the response to disease is a powerful tool to buttress social divisions and prejudices. All three examples demonstrate some of the stereotypical responses of anxious and frightened individuals and groups confronted by the ravages of disease. Flight and denial come first, followed by the scapegoating of those who are judged to be different by virtue of religious beliefs, cultural practices, or economic status. These social reactions reveal our ambiguities about the meaning of such diseases while furnishing convenient targets for projecting responsibilities and blame. The stranger, the Jew, the

poor, the immigrant—all were victims of discrimination in the cases presented in this chapter, their deviance vindicated by the fact that the epidemics claimed a disproportionate number of casualties among them. Here the parallels to AIDS are not difficult to see. If history has a role to play in the present AIDS crisis, it is to restore public memory about our behavior during past epidemics and to continue to raise questions about the meaning and consequences of disease.

Notes