The Coming Plague

by Laurie Garrett

  During 1987 more than 350 items of AIDS-related legislation were debated by politicians in U.S. states, most of them aimed at restricting the activities of HIV-positive individuals or at mandating testing of various population groups.

  In June 1987, Howard Phillips, who had influence at the White House because he chaired a powerful right-wing group dubbed the Conservative Caucus, called for passage of a federal law giving “every hospital, every private business, every property owner, every school … the right to [HIV] test people who seek to use its facilities.” And he said that “quarantining is something that we have to consider.”

  The foci of attack were homosexuals, “immoral lifestyles,” drug users, and sinners—the purported purveyors of viral ruin. Like their Islamic counterparts in the Middle East, many Christian political leaders in the United States were convinced that there was a religious message to be derived from AIDS, an epidemic that would best be stopped through moral virtue.

  The year 1987 was unique in recent American history in that Christian moralists ran against one another in national elections, and a disease rose to the dubious status of a pivotal issue in state, federal, even presidential elections.

  Ronald Reagan’s second term in the White House wasn’t scheduled to end until January 1989, but campaigning for the November 1988 election began extraordinarily early. His Vice President wanted to be next in line for the job, but George Bush was no shoo-in. Sensing that the national mood was volatile, and no single issue or candidate had yet captured widespread support, more than a dozen men were already stumping for office in the spring of 1987, a full year before the first round of scheduled primary elections. And right up until election day in November 1988, AIDS would figure prominently in their campaigns.

  Pat Robertson, a Baptist minister and founder of television’s Christian Broadcasting Network, ran against Vice President George Bush in the Republican Party primaries. Robertson maintained that scientists were “frankly lying” when they claimed that HIV could be transmitted heterosexually, and asserted that condoms were useless to prevent infection. He supported the right of employers to fire and landlords to evict people who were infected with the virus. And he told his Christian followers that they were engaged in “a holy war” against the debauchery and decadence that he said were at the root of AIDS.16

  The Moral Majority, a Christian fundamentalist political body led by the Reverend Jerry Falwell, had long proclaimed that AIDS was the wrath of God against homosexuals. By 1987 the organization, which had backed the previous presidential election of Ronald Reagan, was nervous about supporting Reagan’s heir apparent. AIDS was one reason for that nervousness, as the organization felt that George Bush might cave in to the “AIDS Lobby,” as patient advocates were called, and allow sexually explicit education about the disease. Even federally funded basic research on AIDS was opposed by the group.

  “What I see is a commitment to spend our tax dollars on research to allow these diseased homosexuals to go back to their perverted practices without any standards of accountability,” declared Moral Majority director Ronald S. Godwin.

  In his first major speech addressing the AIDS epidemic, delivered before the College of Physicians in Philadelphia on April 2, 1987, President Reagan assured the nation—for the first time—that he was concerned about AIDS and considered it “Public Enemy Number One.”

  “The federal role must be to give educators accurate information about the disease. How that information is used must be up to schools and parents, not government,” Reagan said. “But let’s be honest with ourselves. AIDS information cannot be what some call ‘value neutral.’ After all, when it comes to preventing AIDS, don’t medicine and morality teach the same lessons? … I think that abstinence has been lacking in much of the education.”

  The President’s comments reflected an ongoing dispute within his administration over the proper tactics for control of AIDS and prevention of the emergence of HIV in geographic and demographic parts of the country not yet touched by the virus. Reagan’s Surgeon General, Dr. C. Everett Koop, wanted frank discussion of abstention, the AIDS epidemic, and safe sex to be conducted in the nation’s schools. But Reagan’s Secretary of Education, William Bennett, adamantly opposed such plans, favoring instead efforts to identify and control HIV carriers through compulsory HIV testing of all hospital patients, marriage license applicants, prison inmates, and foreigners applying for immigration visas.17

  Vice President Bush was straddling his roles as adviser to Reagan and candidate for the presidency. He played to voters on the right, calling for mandatory marriage license HIV tests and public identification of people who were infected.

  It all came to a head in Washington, D.C., June 1–5, 1987. More than 10,000 scientists, physicians, and reporters descended upon the nation’s capital for the Third International Conference on AIDS.

  In the vast expanse of the Hilton Hotel’s conference room, scientists searched for seats, shielding their squinting eyes from the glare of television lights that created, alternately, bright areas and deep, eerie shadows. Around the periphery milled clusters of activists, dressed in black jeans and black-and-white T-shirts emblazoned with Act Up slogans. The hall was filled with nervous energy that confused most of the foreign scientists: for four days they would witness a uniquely American exercise in democracy and confrontation that some would find distasteful, others inspiring.

  The keynote speaker, U.S. Surgeon General C. Everett Koop, dressed in his starched white Public Health Service uniform, looked at the sea of enthusiastic scientists and activists with genuine surprise. What began as a polite reception swelled into nearly hysterical cheering, chanting, shouting, and foot-stomping as thousands of activists and American scientists signaled their support for Koop’s dissident position within the Reagan administration. Koop was stunned. Just two years earlier most of the people in the room would have booed him off the stage because of his staunch, often radical opposition to abortion. But now they gave him a hero’s welcome unlike any the seventy-one-year-old Brooklyn-born physician had experienced.

  “Stop it! You’re embarrassing me!” he shouted, and like obedient schoolchildren, the crowd fell silent, took their seats, and behaved themselves.

  In contrast, when presidential candidate George Bush took to the podium, activists stood silently, their backs turned to the Vice President, many holding placards aloft condemning Reagan administration policies. Cameras rolled, photographers’ bulbs flashed, and hundreds of scientists stood one by one to join the activists in turning their backs on the Vice President of the United States.

  On the final day of the gathering, American and French scientists took the podium together to denounce not only the Reagan administration’s policies but those of governments all over the world that, they said, were “based on irrational fears rather than science.” They urged scientists to sign a petition calling for an end to discriminatory HIV-testing policies, an end to immigration and travel restrictions for people with HIV, and all other forms of what they considered repressive approaches to AIDS control.

  “AIDS is a touchstone of politics, of racism, of bigotry,” Mann told the conferees. “We see a rising wave of stigmatism around the world. AIDS has become a threat to free travel and global movement. People all over the world are seeking answers—simple answers—as the pandemic spreads. People are promoting sex cards, tattoos, quarantines, police lists, deportations, home burnings, incarcerations of select population groups.

  “How our societies treat HIV-positive individuals will test our collective moral strength. This test will present itself with increasing challenge in the coming years.”

  Though Mann’s remarks received thunderous applause that day in Washington, and were carried by the media worldwide, the m
essage many powerful politicians derived from the Third International Conference on AIDS was quite the opposite. They saw shouting homosexuals showing disrespect for national leaders, and upstart scientists daring to tell them how to govern. And they didn’t like it.

  Two weeks after the close of the AIDS conference the U.S. Congress voted unanimously—96 to 0—to mandate HIV tests for all applicants for legal immigration to the United States.18 The same week governors of three states—Minnesota, Texas, and Colorado—signed laws permitting local authorities to quarantine indefinitely HIV-positive individuals who seemed by virtue of their sexual activities to pose a threat to society.

  Throughout the summer of 1987 debates raged in state and federal legislative assemblies over restrictive versus educative approaches to controlling the spread of AIDS. And with the autumn came both more action inside the U.S. Congress and an escalation of presidential electioneering. In October the U.S. Senate voted nearly unanimously—94 to 2—to cut off all federal funds for AIDS education efforts targeted at homosexuals. At issue was a comic book designed by a New York men’s group that depicted graphically how men could safely have sex with one another in the midst of the AIDS epidemic.

  “Christian ethics cry out for me to do something,” Republican Senator Jesse Helms said, claiming the comic books would promote sodomy in America. “I call a spade a spade, a perverted human being a perverted human being. This subject matter is so obscene, so revolting, it is difficult for me to stand here and talk about it. I may throw up.”

  By the time the world’s Ministers of Health gathered two months later in London, the United States had federal laws requiring HIV tests of foreign students, immigrants, long-time visitors, all military personnel and applicants for military service, U.S. overseas foreign service personnel, and applicants for the domestic youth employment service called the Job Corps. Entry to the United States could be barred to any noncitizen known to be HIV-positive, and though Bush had in oratory opposed discrimination against people with AIDS, HIV-positive applicants for foreign service, military, or Job Corps positions were, by law, denied employment.

  Before the London meeting the GPA staff had reviewed all the legal and political activities surrounding AIDS and concluded that they were witnessing, in slow motion, many of the same social responses that had followed the arrival of the plague in fourteenth-century Europe. In both cases there were actually three different social epidemics within the larger biological epidemic.

  First, with the initial emergence of the microbe—plague bacteria or HIV—came denial in all tiers of society. The tendency was to ignore the microbial threat, or assume only “they”—some distinct subpopulation of society—were at risk. The microbes exploited such denial, spreading rapidly while humans made no attempts, through their personal or collective behaviors, to block any of the avenues of transmission of the organisms.

  The second social epidemic was fear. Some event in the biological epidemic would suddenly shock a society out of its state of denial, propelling people into a state of group terror. In fourteenth-century Europe it was often the plague death of a popular cleric or a local lord or the sudden public expiration of a child that prompted panic. The timescale was quick: plague-infested rats might arrive in a town on Tuesday, local human deaths might begin in the harbor area by Thursday or Friday, and a riveting event could spark widespread panic by the middle of the following week.

  But AIDS was a slow killer, and the biological epidemic unfolded in each country over a span of many months or years. So the first social denial stage might persist for over a decade. Fear might also linger for years, giving rise to all sorts of panic responses and inappropriate actions, such as setting fire to the home of two HIV-positive children with hemophilia in Florida.

  Eventually, the Programme staff knew, the social epidemic of fear usually yielded to a wake of repression. Fear-driven government response was usually irrational, prompting attacks on the victims of disease, rather than the microbes. During the plague such fear-driven repression led to the wholesale slaughter of Jews and of women accused of witchcraft. Though outright genocide certainly hadn’t surfaced in response to AIDS, Mann’s staff felt certain that in the absence of strong political leadership guiding populaces toward rationality, the epidemic could have violent consequences in some societies.

  As HIV emerged in new areas of the world, Mann hoped to find a way to break this chain of social epidemics; to push governments out of denial before they had an epidemic on their hands; or failing that, to move a society out of fear to effective action, rather than panic-driven repression. The GPA group knew that they were breaking new ground, that few societies had ever in history responded wisely or rationally to major epidemics, and that lessons learned with AIDS could be applied to combating future emergences of all sorts of microbes. They searched for answers.

  In Nigeria, Dr. F. Soyinka studied his society’s response to AIDS in 1987. Nigeria had very few cases of the disease, as it was located far from Africa’s AIDS epicenter. Nevertheless, Soyinka and other physicians knew it was only a matter of time before HIV took its toll in Nigeria, so they waged a massive monthlong television, radio, and newspaper campaign to warn the public. At the campaign’s end, Soyinka surveyed residents of Lagos.

  He was sadly surprised to discover that “85 percent believe AIDS is a disease of the white man. They believe it can only be gotten if you have sex with a white man.”

  A 1987 Gallup poll conducted in thirty-five nations showed that 96.5 percent of the people questioned had heard of AIDS, but most respondents were deeply confused about how dangerous the virus might be, how one got infected, and which activities put a person at risk. Similarly, U.S. CDC surveys year after year revealed that nearly every adult American had heard of AIDS and knew that it was caused by a virus. But about half thought one could become infected by donating blood, by being bitten by an insect, and/or by sitting on a public toilet.

  Throughout the world there was an alarming confusion between the myths and the realities of AIDS, producing either continued denial or highly exaggerated fear.

  A complicating factor unique to AIDS and other sexually transmitted diseases was the nearly universal dislike of condoms. All over the world, men felt that condoms diminished their pleasure and women had little or no control over their use. Nobody enjoyed talking about condoms during lovemaking, and it could be dangerous for a woman to request that her lover or husband use one: there were widespread reports of men beating their wives or partners in response to such requests.

  Studies of gay male behavior in San Francisco showed that crucial to individual protective action, such as consistent use of condoms, was a high level of fear, brought about by witnessing the deterioration and AIDS death of a close friend, relative, or lover. Similarly, on a societal scale it was apparent that few cultures were able to confront AIDS until the death toll had become sufficiently high to have given more than 10 percent of all adults a firsthand view of the horrendous disease.

  But that was unacceptable. How could Jonathan Mann, the GPA staff, the World Health Organization, or the planet’s citizenry sit back and wait for a massive death toll before taking effective action? How could they allow the microbes to emerge in one geographic or cultural place after another, infect tens of thousands of people, slowly—over a period of years—cause visible disease and deaths, and be utterly endemic to the societies before action was then taken to stave off an epidemic?19

  Studies all over the world were revealing the scale of the problem. For example, by 1987 more than 5 percent of the adult population of Brazzaville, Congo, were infected with HIV, and the visible AIDS death toll was already obvious to even the casual observer. Yet researcher Marc Lallemont found that pregnant women in the city were in “an almost complete state of denial, perhaps the most complete I’ve ever seen.” Lallemont surveyed hundreds o
f women who were making prenatal visits to local clinics and discovered that more than half of them insisted AIDS was caused by mosquito bites, despite numerous government educational campaigns stating just the opposite and warning about sexual transmission of the disease.20

  In 1986 the U.K. government launched one of the highest-profile AIDS education campaigns seen anywhere in the world. It was a case where most of the elements for success appeared to be in place: top-level political will, resources, national television accessibility, and a heightened media interest. Yet the campaign was eventually judged a failure, as it succeeded in raising AIDS awareness and fear but failed to put a dent in public misperceptions about how the virus was transmitted or general disdain for those who carried HIV.21

  In no country, it seemed, had a government found the secret to preventing further spread of HIV once the epidemic became endemic.22

  At the Global Programme on AIDS, Manuel Carballo said that the epidemic was forcing researchers all over the world to evaluate—and reevaluate—the effectiveness of a whole battery of standard public health weapons, in hopes that something besides a chilling death toll could motivate individuals and governments to take rational steps to protect themselves from the virus.

  “What makes the AIDS effort especially difficult,” Carballo said one afternoon shortly before the London Summit, “is that those who are at greatest risk are those who are divorced from traditional values and culture. They have had to innovate new cultures. They find friends in bars and clubs. And nothing in the relationships is stable.”