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.