AIDS and the rise of the behaviour police

Author and doctor Michael Fitzpatrick introduces an essay by Philip Alcabes.

According to an article published on the BBC News website last week, it was the tombstones and icebergs that saved Britain from the plague of AIDS:

‘Under a darkened sky, a volcano erupts. Doom-laden images of cascading rocks give way to shots of a tombstone being chiselled. “There is now a danger that has become a threat to us all”, intones actor John Hurt ominously in a voiceover. “It is a deadly disease and there is no known cure.” The word etched on to the blackened background is revealed – AIDS. “Don’t die of ignorance”, runs the slogan.’

In the feature written for World Aids Day, Jon Kelly claimed that the shocking, ‘apocalyptic’ message of the campaign launched by the British government in 1986 was successful in preventing the spread of HIV in Britain on a similar scale to the epidemic in Africa. In truth, as I argued at the time in a pamphlet co-written with Don Milligan and titled The Truth About the AIDS Panic, given the low prevalence of HIV and the particular characteristics of its spread, there was no good evidence that there was ever likely to be a major heterosexual epidemic of AIDS in Britain – a position vindicated over the past 25 years.

And yet, Kelly’s article offers former health minister Norman Fowler and leading AIDS campaigner Nick Partridge, both appointed knights of the realm for their services to the safe-sex crusade, the opportunity to congratulate themselves on saving the nation from ‘a deadly disease’ that ‘was a threat to everyone’. In response to the preposterous posturing of the veterans of the tombstones-and-icebergs campaign, we publish here an extract from Philip Alcabes’ 2009 book Dread: How Fear and Fantasy Have Fuelled Epidemics from The Black Death to Avian Flu, in which he identifies the panic over AIDS in the late 1980s as a new sort of social disorder: a ‘behavioural epidemic’.

AIDS: the behavioural epidemic

By Philip Alcabes

Until at least the mid-twentieth century, the simple causal narrative of germs and disease allowed people to suspect the poor or the foreign. But AIDS exploded the myth of the conquest of contagion and seemed to invalidate that simple causal (germ) story on which the conquest myth was based.

HIV/AIDS could not be comprehended by attending only to infection and the virus’s ostensible effect. Implicitly, we would fail to recognise the unprecedented nature of this disease were we to name it after the causative virus alone (HIV disease, say), and we would fail to recognise the true inner source of its emergence were we to call it the old-fashioned acquired immune deficiency syndrome. Withdrawing from the world of observables and implying that what is inside (an infection, imprudence, impiety, or immorality) is the same as what is outside (a disease), ‘HIV/AIDS’ effectively illustrated a new epidemic narrative wherein there were threats emerging from so deep within individual psyches or society’s soul that the cause could not be identified except by referring to the outcome. If you had the disease, you had whatever caused it.

After AIDS had been around for a decade, it seemed as if the simple certainties of germ theory and the hopes of eugenic theory had been repackaged, with the putative cause no longer an invisible germ but an invisible behaviour – unprotected sex. Society’s dread of instability was remade. We ourselves were the threat.

Gay activists were wrong to see the US federal government as entirely inactive on AIDS. On the contrary, AIDS was the subject of considerable activity at many levels of government – but the activity was toward shutting out any understanding of AIDS other than as a matter of behavioural excess. AIDS quickly became a behavioural epidemic.

That health professionals in the United States had to fight in order to do nothing more in response to AIDS than proscribe sex with ‘multiple partners’ or promote the use of latex condoms shows how hard it was for Americans to see AIDS as anything other than an outbreak of bad behaviour. Although a blood test for exposure to the AIDS virus went into use for screening blood donations in late 1984 and became commercially available in 1985, there was no policy on testing for the virus until 1987, when the definition of AIDS expanded to include diagnosis by blood test of HIV infection.

But virtually all constituencies could agree to see AIDS as a matter of behaviour. As John-Manuel Andriote recounts in Victory Deferred, his masterful history of AIDS in relation to the gay movement, gay men felt they had to dispel the opprobrium of American society by making sex safer. To accomplish safer sex required touting the condom.

The old truth that each disease is caused by its own germ had always been too simple to describe an epidemic both fully and validly, and with AIDS it came at last into question. Indeed, whether HIV was a necessary cause of AIDS became a topic of some controversy. But when the adequacy of the germ explanation gave way, it did not spur a richer and truer understanding. We did not replace germ theory with a sense that epidemic disease arises when a complex of social factors conjoin and a germ opportunistically enters the group of people caught by those complications (although some who studied AIDS did their best to popularise this view). We began to speak as if we were sceptical that there could be any tangible cause of an epidemic at all. Instead of causes we spoke of risks, and when we spoke of risks we often meant something very vague – an amorphous combination of vulnerability, poor self-esteem, and imprudent behaviour.

As the AIDS toll mounted, health officials, gay leaders, academics, the media and essentially everyone else who was involved in the AIDS world entered the agreement that behaviour was the key to AIDS – key to causing it, understanding it, and controlling it. Gay activists and liberal health professionals created an unlikely alliance with the evangelists (like Jerry Falwell) and the social conservatives (like Pat Buchanan), who saw homosexual behaviour as a threat. The health officials and gay leaders thought behaviour was important to social welfare. The evangelists and conservatives thought behaviour was important to public morality.

As early as 1986, the report of a meeting of AIDS scientists at the Coolfont Center in West Virginia emphasised that information and educational campaigns were essential to AIDS prevention. A report by the National Academy of Science’s Institute of Medicine that same year found that AIDS education in the United States was ‘woefully inadequate’. The US Surgeon General’s first report on AIDS, also issued in 1986, advocated ‘frank, open discussions on AIDS’ between parents and children. Early in 1987, the British government sent a pamphlet to every household that read, ‘AIDS. Don’t die of ignorance.’ With information about behaviour at the centre of the new epidemic, everybody could be on equal footing in their distress.

The turn from risk group to risk behaviour was a sign of an important change in thinking. The epidemiologists’ statement of risk pertains exclusively to groups, a claim about the relatively high probability of an event (AIDS, in this case) occurring within the group compared with the probability among the public at large. The statement about risk behaviour signalled a shift from describing epidemics in terms of groups to blaming them on our, or someone’s, behaviour. Risky behaviour was said to be the cause of AIDS, therefore, with ‘risky’ standing for almost anything that could have to do with sex and, usually, what the speaker’s or writer’s audience would find distasteful.

By the 1990s, acts that might lead the person performing them to become ‘risky’, such as excessive drinking, became relevant to the hazy but overheated discussion of ‘causes of HIV/AIDS’. Even states of mind (despair, ‘AIDS fatigue’) became relevant once the rhetoric of behaviour-as-cause had been introduced. The cause of AIDS moved ever further within the individual and, implicitly, within society.

With this ‘behavioural turn’, a new moralism insisted on mores of sexual propriety – updated for the AIDS era but no less stridently upheld than they had been in the Progressive movement at the turn of the century. In American culture, unprotected sex came to be discussed in pitying or disapproving tones, sometimes seeming tantamount to sin. If the AIDS discussion abandoned old assumptions about germs and tensions about wealth, it acquired equally powerful new ones about prudence, opportunity and social compact.

Condoms came out of the closet. By 1988, Surgeon General C Everett Koop was able to mail to every household in America a pamphlet advising that a condom be used for intercourse if it was impossible to be in a mutually monogamous relationship. There was debate over whether and how condoms could be advertised on television. The archdiocese of New York opposed a plan to make condoms available in New York City’s public schools, leading to cessation of the programme. The activist organisation ACT UP retaliated by staging a die-in at St Patrick’s Cathedral in New York City in 1989, in part to dramatise the conflict between the church’s moral stance about the unnaturalness of homosexuality and its belief in the sanctity of life but also, pointedly, to direct attention to the church’s refusal to endorse condom campaigns.

In the ‘behavioural turn’, everyone would agree to revile sexual transgression. The old disapproval of the sexually licentious, once couched in terms of religious impiety, came back in the new terms of imprudence about health. There were differences in the definition of transgression, to be sure. Most health professionals saw no particular threat in same-sex intercourse per se, only in the way and frequency with which it was conducted. The other school saw a deep moral threat in same-sex intercourse, at whatever frequency. But those lines blurred and changed over time. The centrepiece of the agreement was that the public’s health depended on adjusting behaviour to conform sexually.

AIDS policy would become little more than delivering reminders about how that conformity should be accomplished. It would come to be called ‘health education’ or, in a reminder about the new elusiveness of cause, ‘risk-reduction education’. But it would be, in essence, no different from the sexual messages of the preceding centuries: sexual misadventure leads to ruin.

Educating people about healthful habits had been a part of the American public health movement since the early 1900s. But before the advent of AIDS, never had the entirety of disease-prevention policy been to tell people what they should stop doing. Even the high moralism of VD control in the Progressive era advocated Wasserman testing and control of prostitution as well as reform of sexual habits. In the AIDS era, behaviour control was disease control.

The condom became the iconic assertion of the impending ‘conquest’ of AIDS – not the way germs were supposedly conquered through vaccination in the twentieth century but through education about avoiding risk. The altar of safe sex was one at which everyone could worship – gay liberationists, health officials and politicians alike. The condom became a symbol of safe sex to those who wanted to preserve liberties around sexual choice.

Debate did continue over what form the education about sex and AIDS should take – should it be abstinence until and outside marriage; should it be so-called partner reduction; should it be condom promotion? But that was a shell game. What role parents and other non-professionals should take in setting education policy is an important question, reflected in the debate over AIDS prevention education. But there was no important public-health question at stake. By the late 1980s and early 1990s, in the United States and Western Europe, the AIDS virus was moving indolently through sexual contact. In those circumstances, the exact mode by which prevention of sexual spread was implemented would have made little difference to the overall level of infection in the population. Reducing the rate at which new sex partners are acquired, increasing condom use, delaying sexual debut, increasing monogamy, or any combination thereof might have made a small difference if everyone adopted the recommended behaviour. But with sexual spread of virus a low-frequency event, no intervention could have made a big difference at the population level.

Condoms are very effective at preventing transmission of the AIDS virus during intercourse, if one partner is infected and the other is not. Recommending condoms to people who are in such a situation is good advice. But with the virus spreading slowly, the average chance that one’s next sexual contact would be with a highly infectious person is very small. Under these circumstances, to make a substantial difference to the overall prevalence of infection would require virtually the entire population using condoms for almost every instance of intercourse.

Philip Alcabes is the author of Dread: How Fear and Fantasy Have Fuelled Epidemics from the Black Death to the Avian Flu, published by Public Affairs. The above essay is an edited extract from the book. (Buy Dread from Amazon (UK).)