Familiar Pattern : AIDS Adds to History of Epidemics

An incurable disease. . . . Highly contagious. . . . Fatal to nearly all who contract it. . . . Its victims shunned by society, even by some members of the medical community. . . . Its cause: unknown, except to religious fundamentalists who proclaim it God’s wrath against sin and perversion. . . . The death toll: rising.

A description of the AIDS epidemic?

To be sure.

But that description also fits virtually every major human epidemic going back as early as 4000 BC in Egypt with leprosy, continuing through the classical world with Antonine plague (probably an outbreak of measles that at its height is said to have killed 5,000 people a day in Rome). It moves into the Middle Ages in Europe with syphilis and bubonic plague, into the 18th and 19th centuries with cholera and tuberculosis and finally into the 20th Century with influenza, polio and even legionnaire’s disease.

Denial and Hysteria

Indeed, nearly every such virulent outbreak of illness seems to carry with it not one but two epidemics: the physical manifestations of the disease itself and society’s often predictable reactions to it--denial at first, followed by hysteria, a search for scapegoats, an onrush of commercial exploiters and, finally, though not always, improved public health standards and scientific insights that significantly prolong life expectancies.

“If you look at what’s happening today with AIDS and you look back (six centuries ago) and see what was happening with bubonic plague, it seems to me we aren’t so far ahead from previous eras, despite all of our medical technology, despite all of our sophistication,” said George S. Rousseau, a UCLA English professor who is doing research on the connections between medicine and literature.

Explain the Unexplainable

“There really is a constant throughout history in the response to epidemics. . . . More than anything, there is a need to mythologize disease”--to explain the seemingly unexplainable, he said.

More often than not, the mythologies inspired by epidemics have made their way into the popular culture, often transforming the arts and literature, even the language we speak. Some epidemics also have changed the course of history. Scholars now believe, for instance, that the bubonic plague profoundly altered the face of Europe--collapsing its economy, rupturing its bonds of feudalism, fundamentally changing religion. Others argue that syphilis helped usher in the dramatic changes in life styles that characterized the Victorian Era and the Age of Puritanism.

The AIDS epidemic is hardly likely to have such profound effects. But “some kind of permanent changes in life styles will surely come about as the result of AIDS,” said Brian Henderson, professor of preventive medicine at USC and director of the university’s Norris Cancer Center. “For now, we can only speculate what they will be.”

It remains to be seen whether a cure for the deadly syndrome or a vaccine to protect against it will be found. What is clear, however, is that only five years into the AIDS crisis, most of mankind’s historical reactions to epidemics have already begun to resurface.

When acquired immune deficiency syndrome was identified in the spring of 1981 it was thought not to be contagious. It didn’t even have a name until 1983. AIDS ravages a victim’s immune system, rendering it helpless in the face of innumerable infections and cancers.

Early on, it was dubbed the Gay Epidemic. Then it was said to be a Haitian disease. Soon intravenous drug users were implicated. By Feb. 10, 1986, there had been a total of 17,361 reported cases of the syndrome, and 9,112 deaths. But many more--perhaps 2 million individuals--were thought to be carriers.

Where the medical profession could offer neither hope nor protection, commercial exploiters moved quickly to fill the void. Gay sex shops sold gels and creams that promised to “protect” users. Newly created clinics offered to sell identity cards to those who tested negative for AIDS. Newsletters promised employers the latest legal information about the epidemic.

Overnight, the victims and their families had become society’s new “untouchables.”

Even though evidence mounted by the week that quarantines would do nothing to stop the disease’s spread, politicians in California, Texas and Ohio pushed for legislation to isolate AIDS victims.

Some were fired from their jobs. Others were denied housing. Children were barred from school. Even the dead were shunned, their bodies left unwashed in funeral homes.

Man has never been particularly gracious in the face of disease. Fear of contagion--and ignorance about the source of an epidemic--have often led to quite bizarre behavior and sometimes barbaric practices.

When the plague struck Europe in the mid-14th Century, killing 25% to 50% of the continent’s population, it left terror in its path. Brothers shunned brothers. Husbands fled wives. Mothers abandoned children. Bodies were dropped in the streets and no one could be found to bury them, not for love or money. That’s how Giovanni Boccaccio, a 14th-Century Italian poet, described the plague in his great secular classic, “The Decameron.”

The disease is an overwhelming infection of the blood that often turns hemorrhages black--hence its name, “the Black Death.” It accompanied the Crusaders and was carried by fleas alongside the silks and spices that Western merchants brought from Asia. It recurred again and again for the next 300 years.

It was “the greatest natural disaster in European history,” according to Robert S. Gottfried, a professor of history at Rutgers University and author of “The Black Death: Natural and Human Disaster in Medieval Europe.”

The plague hit England again in the 17th Century in what became known as the Great London Plague of 1665. At its worst it killed 500 people a day. But society had become more civilized then. The dead were at least laid to rest. But “laid to rest” at that time meant that bodies were tossed into “dead carts” and often crammed into mass graves, according to Daniel Defoe’s account in “A Journal of the Plague Year.” Any person, Defoe said, who tried to accompany a corpse to church or venture near the burying place was threatened with immediate imprisonment.

In the face of this horrible pestilence, society was more concerned with discussing how deep graves should be dug than with providing care for victims--or even feeling compassion for them, Defoe said. (It was during the London plague, in fact, that the six-foot grave was established, a practice that has persisted ever since. Previously, according to Defoe’s editors, the depth of graves had been arbitrary.)

Throughout the ages, each epidemic has spawned strange rituals and bogus remedies to rid society of its scourge.

In ancient Rome, magic was thought to be a preventive for almost everything. Bronze mirrors engraved with demons were hung in nearly every dwelling to drive off sickness.

One popular cure for what was probably an early version of influenza was the cabbage bath. To prepare it, one simply had to collect the urine of people who had recently eaten cabbage. Richard Gallagher in “Diseases That Plague Modern Man,” notes that the wife of the ancient Roman statesman Cato died in such a bath.

Another disease that inspired bizarre remedies in the Middle Ages was syphilis. Seventeenth-Century etchings show charlatans touting “sweat barrels” as a sure remedy. Inside the wooden cases, victims sat above live coals.

Such an extreme step was perhaps not surprising, however misguided, given the serious nature of syphilis. Until the advent of penicillin in the 1940s, syphilis could result in the deterioration of flesh and bones, and even lead to blindness and insanity.

But by the 17th Century, fear of the Black Death had become so intense that some people actually set out to contract venereal disease, believing that those with syphilis would be immune to bubonic plague.

Singing and dancing were also thought to be effective disease-prevention measures. Two of the most common were the dance of death, or danse macabre, and Saint Vitus’ dance (today a name for chorea, a disorder of the nervous system).

Saint Vitus’ dance, which became popular in the medieval period, apparently imitated the epilepsy-like seizures that attacked victims of the bubonic plague. They became so convulsive and frantic, foaming at the mouth and flinging themselves on the ground, that, scholars now say, the dances turned into a kind of mass hysteria.

The wild, leaping dance spread from town to town and from country to country. In Germany and Italy, church officials tried to stop the dancers as they moved through the streets, but the efforts were in vain. Gathering hundreds and thousands of followers, it continued throughout the 14th and 15th centuries, until, like the epidemics that spawned it, the dance mysteriously died out.

During outbreaks of various kinds of pestilence throughout Europe, the “difficult” cases--that is, the victims who failed either to recover or to die--were taken to cathedrals. There, they were bound together, often dozens at a time, and left, as Gallagher describes it, “in their own filth until they decided to permit faith healing to cure them, or until they died.”

Many diseases that reached epidemic proportions in Europe were of unknown origin. “People were simply said to have died of fevers and fluxes (that is, diarrhea) and rashes,” said Dr. Thomas F. Paine, professor emeritus of medicine at Vanderbilt University.

The remedies used to fight those illness were often equally mysterious. Chants were sung, incantations said and magical potions applied or consumed.

One disease of unknown origin in 15th-Century England was the “sweating sickness,” characterized by pounding heart, vomiting and intolerably high fevers. Some medical experts now believe that the English “sweates” may have been one of the thousands of epidemics of influenza that had spread throughout the world over the centuries.

Whatever the cause, Gallagher noted: “Death was blitzkrieg swift. Victims went in a day, some within a few hours. Farmers kissed their wives goodby in the morning and (found) them dead at noon.”

They, like victims of many other diseases, were subjected to one of the most ancient and barbaric forms of surgery: bloodletting. If they did not bleed to death, patients were so weakened that they had little chance of surviving the “cure.”

Ironically, that may have been precisely what some people wanted in the face of a horrible epidemic.

Although only a few are alive today to remember it, one of the worst pandemics--indeed, now believed to be the third most devastating worldwide epidemic of all time--was the influenza outbreak of 1918-19.

The symptoms are familiar, but the death toll was not. By conservative estimates, it took 20 million lives; some believe it was closer to 50 million. Fifty percent of the dead were between 20 and 40, presumably the most vital and productive years of life. In the United States alone, half a million people died, and another 20 million fell sick.

Little could be done to stop the flu or its pneumonic complications in 1918, although various forms of isolation were attempted. In San Francisco, for a time, all citizens were required to wear face masks.

The fear that such an epidemic could cause was evident, according to Gallagher, in the reaction of one Chicago man. A laborer whose wife and four children were terminally ill with flu, he shouted from his house: “I’ll cure them my own way!”

He slit their throats.

By contrast, the rituals and remedies of earlier times seem innocuous enough. Yet many of them were probably no less lethal.

In response to bubonic plague in 17th-Century England, people wore “plague gowns”--perhaps, notes UCLA’s Rousseau, a well-intentioned precursor of today’s antiseptic surgical gown, yet of no help whatsoever to those who were so likely to die from the pestilence. They also ate “plague cakes”--mysterious herbal concoctions--as well as what Defoe called a variety of “odious and fatal preparations,” such as mercury, which, if they did not poison their users, at least lulled them into thinking they were protected against disease when they were not.

As Defoe put it, the fearful ran to “quacks and mountbanks, and every practicing old woman for medicines and remedies; storing themselves with such multitudes of pills, potions, and preservatives, as they were called, that they not only spent their money but even poisoned themselves beforehand for fear of the poison of the infection; and prepared their bodies for the plague, instead of preserving them against it.”

The size of an epidemic often has little impact on the panic it can cause--or the lengths people will go to avoid it.

By historical standards, poliomyelitis, or infantile paralysis, was a relatively minor epidemic. Between 1915 and 1954, when Salk vaccine was introduced, fewer than half a million people, mostly children, were affected in the United States, and most of them exhibited no symptoms or experienced only minor illness. During the 40 years of the epidemic, fewer than 60,000 people died from polio--nearly the same number that now die each year because of tobacco, according to James Mason, director of the Centers for Disease Control in Atlanta.

It is known that the polio virus enters the body through the mouth and is therefore transmitted almost entirely by contact with a person who is already infected. Yet, fearful that it might be caused by insects, towns across America in the 1940s sprayed substantial quantities of the highly toxic pesticide DDT.

Parents also did whatever they could to ensure that their children were not exposed to polio. Swimming pools were frequently off-limits in summer. School openings in many Midwestern towns were often delayed late into the fall, when the disease was believed to be less virulent. In the summer of 1944, Milwaukee went so far as to quarantine children in their own backyards.

Over the years, quarantine and isolation have certainly been the most common, if not always the most effective, way to fight epidemics.

The Old Testament describes in considerable detail what should be done with lepers.

According to Leviticus, “the leper in whom the plague is, his clothes shall be rent, and the hair of his head shall go loose, and he shall cover his upper lip, and shall cry: ‘Unclean, unclean.’ . . . He shall dwell alone.”

In 13th-Century Europe, lepers were literally cast out from society, not allowed to touch their children or have intimate relations with their spouses. Forced into isolated colonies or left to roam homeless in bands, they were made to warn of their presence by shaking rattles as they approached towns. When they came upon someone, they were forced to stand downwind.

“Upon diagnosis, the leper was counted among the dead, and a quasi-requiem Mass was sung for his soul,” Gottfried wrote in his 1983 book. “Earth was shoveled on his feet, symbolizing departure from the mainstream of society.”

“One of the myths about epidemics . . . is that there is somebody to blame--somebody is responsible,” commented Rousseau, the UCLA professor who has been studying the connections between medicine and literature.

The Italians considered syphilis the French disease. The French called it the Italian disease. In the 19th Century, influenza was known as the Spanish disease; throughout the 20th Century it has been labeled the Hong Kong flu or the Asian flu.

“In one sense, the sort of scapegoating that goes on is a way to cut down on anxiety . . . a way to believe that someone else is responsible--that someone else, not us, will get it,” said Charles R. Rosenberg, a historian of medicine at the University of Pennsylvania.

Certainly organized religion has always stood ready to cast the blame for disease on the wicked, especially when the disease could not be otherwise explained.

For instance, when cholera, marked by diarrhea and spasmodic vomiting, first reached epidemic proportions in the United States in the 19th Century, no one suspected that it was caused by filth and unsanitary water and sewage systems. Instead, it was seen by preachers and some moralists, according to Rosenberg in his 1962 book, “The Cholera Years,” as “a scourge, a rod in the hand of God” against sin and perversion.

In the face of epidemics, diseases invariably have become inextricably intertwined with politics and have in some instances changed the course of history.

In the early part of the 19th Century, Hungarian peasants thought that cholera was a plot by the aristocracy to reduce their numbers.

And in his highly regarded history, “Plagues and Peoples,” William H. McNeill, professor of history at the University of Chicago, explains how Hernando Cortez, the 16th-Century Spanish conquistador, could, with fewer than 600 men, conquer the entire Aztec empire of Mexico, whose subjects numbered millions.

The answer, McNeill argues, was smallpox. Having been exposed to the disease for years in Europe, the Spaniards were at least partially immune to it. But an outbreak of it among the Indians, who had never been exposed, proved deadly and quickly reached epidemic proportions. (The disease, brought by early missionaries, appears to have had a similar effect in Hawaii, where the native population was almost eliminated by it. In Alaska, exposure to measles brought by early explorers nearly devastated the natives.)

Although Cortez may not have known of his “biological power” over the Indians of Mexico, certainly Lord Jeffrey Amherst, the man for whom Amherst College is named, seemed to have known what he was doing in Massachusetts in 1763 when he “ordered the blankets infected with smallpox be distributed among enemy tribes,” McNeill said.

In the 14th Century, particularly in Germany and Switzerland, Christians blamed Jews for outbreaks of the bubonic plague. According to the Christian theories, the Jews were poisoning the drinking water--a charge flatly refuted by French doctors who noted that Jews drank the same water as everyone else. Nonetheless, noted Gottfried in his book on the Black Death, whole communities of Jews were slaughtered, their bodies loaded into wine casks and floated down the Rhine--a concerted rise of anti-Semitism that “bordered on genocide.”

In “Diseases that Plague Modern Man,” Gallagher describes the changes wrought by outbreaks of malaria, a debilitating disease now endemic to the tropics and subtropics everywhere. “Few pestilences have brutalized mankind in more criminal fashion than malaria. Every nation afflicted has suffered change for the worse in fortune: Malaria is thought to be one of the forces which toppled Rome. . . . Malaria was likely the undoing of Mesopotamia.”

In “The Black Death,” Gottfried describes how the plague transformed Europe.

The most profound effects, he said, surfaced after the epidemic had subsided. If nothing else, the substantial reduction in the size of the population caused wages to skyrocket and put a premium on new technologies to save work and time (perhaps presaging the Industrial Revolution that was to come several centuries later). Deaths from the plague certainly upset the balance of power between peasants and aristocrats, and challenged the authority of the Catholic Church, which led to the 16th-Century Reformation and the rise of Protestant religions.

The lives of individuals who survive an epidemic are often profoundly altered, according to McNeill, author of “Plagues and Peoples.” It is surely “far too simplistic” to say that one disease--syphilis--could have brought on the Victorian Era or the Great Age of Puritanism, McNeill said, but certainly the sexual restraint that came to characterize those periods was at least partially the result of fears associated with contracting a sexually transmitted disease.

The most obvious fallout from an epidemic is the change that occurs in science and medicine.

Some of the remedies for diseases came about quite accidentally. It was probably largely a matter of luck that a clever country doctor in England in the late 1800s noticed that dairymaids did not get smallpox. Edward Jenner’s theory that the milkmaids had contracted mild cases of cowpox and were therefore immune to smallpox led him to develop an effective vaccine and lay the foundations of immunology as a science.

However they were discovered, scientific insights have relegated a whole host of diseases to the history books. Antibiotics have helped doctors treat syphilis and plague. Vaccines have virtually eliminated measles and polio. Remedies for malaria and cholera have also been developed.

The speed and efficiency with which scientists today can detect and analyze an epidemic became apparent in 1976, when an outbreak of a deadly disease struck conventioneers in a Philadelphia hotel. Although the country may have been seized by fear of legionnaire’s disease, it took epidemiologists less than half a year to identify the super-lethal bacterium responsible for it.

Modern science, however, is not invincible, as the AIDS epidemic clearly illustrates.

Like the flu, another disease that continues to baffle scientists, AIDS is caused by a complex virus that appears to be constantly altering its own structure. Hence a vaccine or a drug is years away at best, researchers say.

In the meantime, AIDS will continue to reverberate through society, as have epidemics through the millennium--a source of fear and consternation, a source of exploitation and discrimination, a source of grief and, for some, a source of inspiration.

Indeed, many experts say, the one true distinction of AIDS, one that makes it different from virtually any other epidemic, is that its sudden and deadly appearance caught modern man by surprise.

“No one under the age of 45 (in this country) has any experience with a contagious, deadly disease,” said David Rothman, director of the Center for the Study of Society and Medicine at Columbia Medical Center.

“If you are older, you can remember something about polio in the summers,” he said. “For the rest of American society, this is a very new experience.”