And the band played on: Politics, People and the Aids Epidemic 
by Randy Shilts.
Viking, 630 pp., £15.95, March 1988, 0 670 82270 1
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Crisis: Heterosexual Behaviour in the Age of Aids 
by William Masters, Virginia Johnson and Robert Kilodny.
Weidenfeld, 243 pp., £9.95, March 1988, 0 297 79392 6
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The Forbidden Zone 
by Michael Lesy.
Deutsch, 250 pp., £11.95, February 1988, 0 233 98203 5
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There is no good news about Aids. With a total of 85,000 cases reported at the beginning of this year the World Health Organisation estimate of the true figure is nearer 150,000. Their global estimate for HIV infection is between five and ten million. Most HIV-positive individuals have no symptons and don’t know they are infected: but the majority of them – possibly all of them – will eventually develop Aids and die; in the meantime, of course, they may infect anyone they have sex with and any children they bear.

Projections for the rest of the century show that a dozen years hence, in the year 2000, barring unprecedentedly rapid progress in the development of a vaccine, or an unpredictable change in the behaviour of the virus, 25 million people are likely to have died or be dying of Aids: that is, half a per cent of present world population – a fraction, but more than the victims of the 1918-19 flu epidemic, more than have been killed in a century of automobile accidents, almost as many as died in two world wars. Such figures would put Acquired Immune Deficiency Syndrome in the TB league, among the greatest killers.

The comparison with tuberculosis suggests a further grim prediction: although effective treatment for tubercular illness has existed for a quarter of a century, it is still one of the leading causes of death in the Third World; similarly, any advances in the treatment or prevention of Aids will benefit Westerners immediately, but their implantation in countries of the Southern hemisphere, including the African Aids epicentres, will certainly be slower and less effective. Aids will be taking its toll in such countries long after it has been contained in the West. Western countries, with their advanced systems of communication and established traditions of preventive medicine, are beginning to slow down the spread of the disease by promoting changes in sexual behaviour among their citizens. Few Third World countries are in a position to do this at all effectively; most are still struggling to establish facilities for primary health care. In the West, the comparative youth of Aids victims has been one of its most shocking features. (In the United States it has displaced homicide as the leading cause of death among males in their twenties and early thirties.) But in other regions of the earth low life-expectancy and the heavier burden of suffering from chronic infectious diseases like tuberculosis, not to speak of malnutrition, blur the effects of any new epidemic. Aids is just one more in a bundle of afflictions.

Randy Shilts argues convincingly in And the band played on, a massive chronicle of the epidemic from its putative origin in the mid-Seventies up to the mid-Eighties, that public health agencies and news media in the United States dawdled in their response to the epidemic because its early victims did not come from the mainstream of society. Newspapers that had put Legionnaire’s Disease and Toxic Shock on the front page fought shy of the new illness because of the homosexual angle; blood banks that could have acted sooner baulked at the expense of making their blood safe from the virus; and gay leaders failed, on the whole, to confront the challenge to sexual mores that the epidemic posed for their constituencies. In the five years from 1980, when the first homosexual men began to fall seriously ill from obscure ailments, to 1985, when Rock Hudson died and Aids became a household word, the story is one of reluctance and embarrassment and delay. Shilts’s heroes are a few isolated teams of scientists in Europe and America who pioneered research in Aids and a handful of gay leaders in New York and San Francisco who withstood vilification from fellow activists and commercial interests in the gay world to lobby for funds to combat the epidemic and campaign against the aspects of homosexual practice that spread it so quickly.

And the band played on is a valuable book: its documentation of the convergence of sexual liberation, scientific medicine and national politics in the early stages of the epidemic is unlikely to be bettered. The story is told in obsessive detail, from the petty rivalries of virologists to the micropolitics of the gay community in California, where Shilts was a reporter on the San Francisco Chronicle, a newspaper he exempts from his general strictures on the press. Some of these minutiae are fascinating, but some are just minutiae. In the case of the doctors and researchers working with Aids patients in California, Michael Lesy’s study of death in America, The Forbidden Zone, though not specifically about Aids, has interviews with many of the same individuals as Shilts’s, and is a good deal more perceptive.

Shilts’s account has been criticised on several grounds, the first of which is his identification – albeit tentative – of a single individual, Patient Zero, a Canadian airline steward named Gaetan Dugas, as the man who brought Aids to America in the late Seventies. The aetiology is dubious: for one thing, frozen blood samples have recently provided evidence of much earlier appearances of the virus in the US. But one takes exception not so much to the perpetuation of the myth of Patient Zero per se as to the chauvinism that makes the question of when Aids crossed the border such a key feature of the narrative. Shilts suggests that the virus reached Europe from Africa in the Seventies and passed either from there or via the West Indies to North America. (Europe, by this account, is experiencing two waves of the epidemic simultaneously: an initial, statistically less significant one from Africa dating back to the Seventies and a second one brought over from America by gay men in the Eighties.) Although Shilts acknowledges the importance of research by French scientists in the identification of the virus, there is not very much about the development of the epidemic in countries other than his own. He is properly sensitive to prejudice against sexual minorities, but his own ethnocentric bias seems to escape him. Americans were dying, he tells us, as though their deaths were worse than others. American news media, he remarks sardonically, only sat up and took notice when the disease started to strike the people who mattered – heterosexuals. But in fact the American news media had been ignoring large numbers of heterosexuals affected by Aids. It was just that these heterosexuals happened to be Africans, not Americans. Until Americans and Europeans – of whatever sexual label – started dying, Aids didn’t even have a name. Once they did, the acronyms began to proliferate: GRID (Gay-Related Immune Deficiency); KS (Kaposi’s Sarcoma); ARC (Aids-Related Complex); HTLV (Human T-Cell Leukemia Virus) I, II and III; finally HIV (Human Immunodeficiency Virus).

Both in England and America it was gays, and doctors working with gay patients, many of whom were gay themselves, who raised the alarm. Health-conscious, well-off, politically-organised gays were an early-warning system, canaries in the mineshaft. In sexually-transmitted diseases, as in sexual liberation itself, gays have been the pioneers and the martyrs. Non-homosexuals should be duly thankful. What, we may inquire, would have happened if Aids had remained a Third World disease, fulminating in the tropics? It could well still be unidentified. And what would have happened if it had come to the West, but not hit on the gay vector, not got into the blood banks, but remained sequestered among intravenous drug-users and migrants from Third World countries, later to spread from these groups into the population at large? These questions are doubly hypothetical, since the geographical routes of transmission of Aids have still not been established with certainty, but in the second case it is likely that the virus would have spead more slowly, more insidiously, and that there would have been a correspondingly greater delay in public response. The accident of gay transmission may have accelerated the establishment of Aids in the West, but it has also accelerated the social response.

Although the epidemic has only just begun to make a significant impact on the death rate, its effect on the public imagination in Western countries is already palpable. Information can travel faster than a virus. Prophylactic doses of anxiety are now distributed by government agencies. The tenor of social life has radically altered. Actual behavioural change is more difficult to assess. Masters and Johnson and their colleague Robert Kolodny argue in Crisis that sexual behaviour in the United States among both homosexuals and heterosexuals has not yet altered enough to make a significant difference. In addition to the time-lapse between infection and the appearance of symptoms, which may allow years of unwitting transmission of the virus, there is evidence that the new high-risk groups – adolescents and promiscuous heterosexuals – are the least responsive to public information campaigns designed to promote safer sex. ‘Safe sex’ itself, that deceptively optimistic oxymoron, comes under examination here. Skin breaks, say MJK, blood spills, condoms slip and tear; to have really safe sex you would have to agree with your prospective partner to get tested for HIV, then remain celibate for six months (the possible time-lapse between infection and the development of the antibody) and both have the test a second time. Only then, and if you still test negative, can you stop worrying and live happily – monogamously – ever after.

Not many people are going to be as careful as this: there is still, after all, as high a risk of death from just taking a car on the road. Aids makes actuaries of us all, however; and risk assessment becomes the order of the day. Pragmatism re-establishes a simulacrum of old morality, but its prohibitions derive not from the expectation of transcendental reckoning, but from mortal fear; its precepts are based not on a sense of the sacred but on medical sanction. Instead of modesty, we have circumspection; instead of courtship, quarantine. There is no discretion here, none of the impure hush of the old morality. The overriding moral imperative becomes sexual honesty – about HIV-status, about infidelity; candour in this zone of lies can be a matter of life and death.

And in order to proscribe you must first describe: the promulgation of this new morality involves overcoming traditional reserve, the kind of unwillingness to articulate the specificities of sex which in the United States kept Aids out of the newspapers and off the screens for those crucial years in the early Eighties. In Western countries Aids has now done what two decades of sexual liberation never quite did: bring frank discussion of sexual practice into prime time. Shilts reports that a director of the US Centres for Disease Control complained that he had to speak to the press about things he would not have dreamt of discussing with his wife. The promotion of restraint on behaviour has certainly involved an extension of acceptable speech, a shift in the effability of sex. The language of sexual ethics now incorporates a clinically precise set of warnings and procedures, a vocabulary derived equally from sexual medicine and gay argot. Randy Shilts’s book is itself an example of this, but the liberation of the language of sex has gone further: anal intercourse enters the school curriculum; fist-fucking is found on the op-ed page.

Such acts, esoteric or otherwise, are admitted to everyday speech at the moment they become uncountenanceable in life; simultaneous constraints on practice and dispensations in parlance define the new terrain of sex. Perhaps we can anticipate an era of inventiveness in sexual fantasy, a silver age of erotica. More important, we may be able to look forward to a new history of sexual desire and practice. If Aids is the death warrant of the sexual revolution, it has at least made it possible to write the obituary.

The new dispensation should also ensure that sexual embarrassment does not connive in future to delay response to epidemic disease. Aids is not, of course, the first instance of this. The history of sexually-transmitted diseases is largely one of ignorance and shame. Even during the sexual euphoria of the Sixties and Seventies, when the expansion of sexual opportunity was shadowed by a pandemic of STDs, the residual decencies did not encourage open discussion of the subject. Antibiotics were enough. There were no public announcements until Aids derailed the sex express. Shilts and Masters & Johnson et al make great play of the failure of social institutions to respond fast enough to the advent of Aids. To us, five years’ delay in tackling a new disease may seem scandalous. But from a historical point of view, it looks like exemplary rapidity. Neither of these books makes much attempt to look at Aids in the context of other public health problems, or as part of the history of sexually-transmitted diseases, or in countries other than the United States. But such comparisons are necessary if we are to understand social responses to the epidemic, the differences being as significant as the similarities.

The closest analogy to Aids in epidemiological terms, syphilis, also a slow, horribly debilitating and potentially fatal disease, largely sexually transmitted but transmissible in utero or through infected blood, a disease whose geographical origin is still disputed, came and went in Europe in waves of varying virulence from the end of the 15th century onwards. Syphilis was one of the first victories for chemotherapy. It was less of a triumph for social medicine. Although the causative agent, the spirochete, was identified in 1905 and the first effective treatment, Salvarsan, was developed in 1910, these discoveries did not manage to stem a post-war intensification of the epidemic which resulted in an estimated one in ten Americans becoming infected by the Twenties. The figure is an estimate because the pathological discretion of medical practitioners prevented the extent of the epidemic being recognised. In the United States, only a long campaign on the part of a few enlightened doctors overcame this conspiracy of silence, bringing syphilis and other infectious diseases under the regulations for communicable diseases, and leading to educational campaigns directed at American troops in the Second World War that prefigure contemporary Aids prevention programmes (though they promoted marital fidelity and moral hygiene rather than safe sex).

In the case of Aids, the period of denial and suppression was much shorter, but the spread of the disease has been much swifter. By the time the virus was identified it was established on three continents. This is due in part to air travel, the ease of trans-oceanic exchange, the international blood trade and the optimal conditions for transmission created in the gay bathhouses: but principally it is due to the fact that Aids, being new in the human population, is more virulent. Aids, as we know, is a peculiarly refractory disease, a disease of diseases, laying the body open to any infection, stripping away epidemiological history – the resistance that millennia of adaptation have bred in human populations. It can nevertheless be assumed that, like other epidemic diseases, it will, in the long run, even in the absence of a vaccine, establish a more stable relationship with its hosts, becoming less infectious or less often fatal, by mutation or selection out of those individuals most susceptible to it, leaving a smaller, more resistant human population.

Such evolutionary manouevres can come about only over generations. There are those who take comfort, even pleasure, in the idea that the fatalities to come represent a purgative response to overpopulation, a rebuke to the species for failing to find other means to control human increase, a reassertion of the balance of nature. Do such people take account of the terrible duration of Aids, the length of time it takes to die, the prospect of a world full of human beings half-way to the grave? There are also those who see Aids as a Biblical plague, the judgment of God on sinners. (God, on this interpretation, would seem to favour lesbians, since they are statistically at least risk.) From the secular point of view, concern for the victims of Aids is the order of the day, but the next few decades may see priority given to the survival of social institutions rather than individuals. Plagues kill people: they can also destroy the societies that sustain them. We can only hope that the global struggle against Aids will revive the spirit of international co-operation, not just in medical research, but in response to the social and demographic distortions introduced by chronic illness and untimely death. Whatever meanings may be ascribed to the epidemic, we are in it together, and together we confront a ubiquity of suffering, suffering that will eventually touch everyone, victims and survivors alike, in every community in every continent.

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Vol. 10 No. 13 · 7 July 1988

In a review of three American books, And the band played on, Crisis: Heterosexual Behaviour in the Age of Aids and The Forbidden Zone, Mr John Ryle (LRB, 19 May) begins: ‘There is no good news about Aids. With a total of 85,000 cases reported at the beginning of this year the World Health Organisation estimate of the true figure is nearer 150,000. Their global estimate for HIV infection is between five and ten million. Most HIV-positive individuals have no symptoms and don’t know they are infected: but the majority of them – possibly all of them – will eventually develop Aids and die; in the meantime, of course, they may infect anyone they have sex with and any children they bear.’ This is hogwash. The word ‘Aids’ is one of the cruellest and silliest neologisms of our time. ‘Aid’ means help, succour, comfort – yet with a hissing sibilant tacked onto the end it becomes a nightmare. It should never be used in front of patients. HIV (Human ImmunoDeficiency Virus) is a perfectly easy name to live with. ‘Aids’ causes panic and despair and has probably done something to facilitate the spread of the disease. In France, not even M. Le Pen could do much with le Sida. He had a go, but was made to look completely ridiculous. HIV is not some gay Götterdämmerung: it is another African virus, a very dangerous one, presenting the greatest challenge to medicine since tuberculosis, but one for which a cure will be found. Any virus, be it chicken-pox, mumps or HIV, will create a kind of mirror image of itself known as an ‘antibody’ which in time will stabilise the infected person. That should be the pattern. But HIV is a very slippery customer. There is no positive evidence of antibodies at work, only negative evidence that a great many infected people are alive. In one case in the US an infected person suddenly became HIV negative. We should, in fact, take Mr Ryle’s own figures. There have been 800,000 infected persons in the United States, of whom 80,000 have died. That means nine survivors to one death. This can mean only one thing: that some mechanism, pharmaceutical or otherwise, is keeping them alive.

One point cannot be emphasised too strongly. An infected person must never use anyone else’s toothbrush or an electric razor. We all have gingivitis from time to time.

What is most horrifying about Mr Ryle’s article is the callous cruelty with which he condemns hundreds of thousands of people to death. If a young man who has just been told that he is HIV positive got hold of the article, the chances are he might commit suicide. There have been many such cases.

Bruce Chatwin
Oxford Team for Research into Infectious Tropical Diseases, Oxford University

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