In 1832, with cholera causing great mortality in US cities, both lay officials and clergymen asked President Andrew Jackson to declare a national day of prayer and repentance in hopes of halting the epidemic. In those days before the bacterial agent that spreads cholera had been isolated, the disease was widely blamed on the despised races: blacks, who were deemed to invite cholera by their lazy habits, and the Irish, who were numerous among the urban poor and famously Catholic (read: too many babies, too much alcohol). Jackson refused to call for nationwide prayer, and was vilified by officials both secular and lay. In 1849, when cholera returned, then-President Zachary Taylor reversed Jackson’s stance, quickly declaring a National Fast Day for “prayer and humiliation.”
Race, as much as science, has been central to the growth of medicine and public health as professions in America. Nineteenth-century physicians distinguished themselves from their competitors in the healing business, cornering the market in part through their embrace of scientific approaches to cure; today, similarly, the medical profession holds off competition from alternative therapies by indulging in “evidence-based medicine.” But, from early on, one of medicine’s less publicized attractions was its capacity to tender rationales for our obsession with race. White people’s suspicion that blacks were morally inferior was perfectly satisfied by prominent physicians’ assertions that African Americans had a greater propensity for disease, imaginary as that propensity turned out to be.
Disease remains tangled with both moral uprightness and race, even today. For instance, history was made in the fall of 1997, after several young women from around Jamestown, in upstate New York, tested positive for HIV and then identified a young African-American man from Brooklyn as a sexual contact. A New York State Supreme Court judge in Chautauqua County authorized public officials to divulge the name of the man, Nushawn Williams, even though Williams (officials claimed) knew himself to be infectious. The media were inflamed: Williams was an “AIDS predator,” a “monster,” a “dirtbag,” a “maggot,” the “bogeyman incarnate.” He had “hundreds of partners.” He “preyed on schoolgirls.” He was a “guy who . . . shot a number of people with a different kind of bullet.”
The legal ruling—the first and, to my knowledge, only breach of New York’s HIV confidentiality law—was justified, said the jurist, as it would allow Williams’s sexual contacts to testify against him, enabling prosecutors to “remove [him] from the community” through application of the state’s public health laws. New York’s HIV law already contained extensive provision for anonymous notification of sex partners. That is, once an individual was identified as having HIV, officials were legally empowered to notify any sex partner of that person about possible exposure to the virus, and to do so without revealing the infected individual’s name. As Thomas Shevory asks in his penetrating assessment of the situation, Notorious H.I.V.: The Media Spectacle of Nushawn Williams, why was the warning to Williams’s partners and prospective partners in and around Jamestown issued by the national news media? Why was Williams’s demonization so public, and so vile?
Although in a society now both racially enlightened and AIDS-frightened it could not be mentioned as determinative, the fact that Williams is black and was living in a largely white part of the country cannot be divorced from the narratives of sexual misbehavior or civic irresponsibility. For a fuller explanation, we have to consider not just race but its ineradicable links with place. And, we would have to take into account not just the sexual threat posed by one black man or even the imagined priapism of black men generally, but how Americans segregate our neighborhoods by race. If we were serious about answering our own specific questions about Nushawn Williams and the media or the general ones about race, behavior, and disease, we would have to discuss Americans’ continued (if unvoiced) dread over sexual miscegenation and the imagined pollution that would otherwise result. Williams pricked and shattered the security of place, closed the distance from Jamestown to both drugs and Brooklyn—meaning, from blacks—that is the prerogative that whiteness is supposed to ensure. To a certain racial complacency, he was a demon.
For an epidemic that began in Africa, then, AIDS’s racial tinge remains surprisingly equivocal. The wasting condition known as Slim disease was first seen in Africa slightly before or just at the time of (accounts vary) the initial US reports of AIDS, in 1981; isolated cases of what was apparently the same disease occurred at least ten years before that. Soon after Slim was described, European and US researchers became interested in what they recognized to be an African version of the disease known in the US as AIDS. In 1984, Projet SIDA (the French acronym for AIDS) was established in Kinshasa to study the new disease. Yet, as late as 1987, some African officials were insisting that AIDS was a foreign disease, imported from elsewhere. American officials, meanwhile, were busy defining “risk groups” in ways that gestured toward blacks: the infamous “4H club” of 1983 referred to the US Centers for Disease Control’s designation of AIDS risk groups as “homosexuals, hemophiliacs, heroin users, and Haitians.” The risk group designation mattered, because it identified for worried Americans the culprits. No matter that the CDC claim they intended only to name the population groups that had higher-than-average rates of AIDS diagnosis; the effect (foreseeable, but conveniently ignored) was that, at a time when many Americans still suspected that AIDS could be “caught” through everyday activities, the four H’s tagged the shady foreigners among us. Americans found that at least some of those suspected—and now officially implicated—in the spreading AIDS disaster had dark skins. Surprise.
No wonder that the origin of the AIDS virus has been a hot potato, positively radiating racial thermals. By the late 1980s it was quite common in the AIDS-stricken poverty neighborhoods of America’s northeast to hear African Americans confidently claim that HIV had been constructed in US government labs in order to kill black people. The contrast between the ability of the federal government to quickly discover and remedy the cause of the Legionnaire’s Disease outbreak, which struck several hundred middle- and older-aged white American Legion members in Philadelphia in the summer of 1976, and its inability to figure out how to stop AIDS from spreading in the neighborhoods where poor black people live was invoked as evidence. The US Public Health Service’s horrendous Tuskegee Experiment was evidence. The high proportion of African Americans among the 40-odd million citizens who had no health insurance was evidence, too. Incredible though the claim about purposive construction of HIV was, it was very hard to argue with the central facts of the evidence. AIDS was more bad news for the black poor in America.
Scientists were convinced, by the 1990s, that the AIDS virus originated in Africa. By the end of the decade, careful molecular-genetic studies had traced the evolutionary tree of HIV, showed the points of divergence from the ancestor simian viruses from which the human AIDS virus clearly evolved, and suggested that the “crossover” point—the time at which the formerly simian virus had undergone enough genetic change to be recognizable as the HIV that infects humans today—was sometime in the middle of the twentieth century. Speculation as to how viruses of chimpanzees or mangabeys could have entered human hosts ran wild among supposedly serious scientists, sometimes including patently racist (and pretty repulsive) sexual allegations.
Complicating the picture, journalist Edward Hooper, in his 1999 book The River: A Journey to the Source of HIV and AIDS, floated the theory that HIV was created not purposively but not quite by accident, by European and American scientists who were producing oral polio vaccine in central Africa in the 1950s. Hooper’s hypothesis was that scientists essentially encouraged HIV to evolve from the pre-existing simian viruses when they indiscriminately pooled monkey cells to grow the poliovirus needed to make vaccine, and then ill-advisedly gave the vaccine to thousands of Africans. Although he was almost certainly wrong on the specifics of HIV’s origin, Hooper raised uncomfortable issues about the blasé attitude of western medical scientists toward Africans’ welfare and offered a legitimate and carefully documented indictment of the slippery morals of researchers conducting vaccine trials. His jabs penetrated deeply into the tissue of the American and British research industries, landing close enough to the bone that Hooper was not merely dismissed but was castigated in print.
In what must be a testament to the enduring power of race myths to perfuse thinking about science in general and AIDS in particular, there is the contrast between what is said about HIV’s origin and what is never said. Not withstanding Hooper, and science’s sharp dismissal of his critiques, the origin discussions almost always revolve around the “practices” or “customs” of “tribal hunters,” “villagers,” or simply “natives” in Africa. They almost never include the central fact that the creation of a new viral species that can infect and harm humans is a rare event: the creation of a species as well suited to wreak havoc among human populations as is HIV so immeasurably improbable that it can essentially only happen in places where there are very, very crowded ecosystems, with plenty of opportunity for genetic material to be swapped around and altered in the process. That is, it could only have happened in richly biodiverse parts of the globe. For reasons that have nothing to do with race or what we humans call culture, HIV could not have become what it is in many parts of the world other than central Africa. But discussions that have nothing to do with race are not, it seems, part of the narrative of AIDS. The ecological accident that made sub-Saharan Africa the birthplace of HIV becomes, in the larger discussion on AIDS, the cultural fact that sub-Saharan Africa was the source of AIDS. Race matters.
Through all the discussions, the to-dos over America’s problems with blackness and whiteness, the debates about origins and ethics, Africans have been dying. In droves. By 2000, the World Health Organization reported, average life expectancy in sub-Saharan Africa was 45 years. All ten of the countries with the shortest lifespans on earth are in sub-Saharan Africa. Life for many Africans would be abrupt and dire even without AIDS. With it, the dying that began with Slim over a quarter-century ago increased continuously. By the mid ’90s there were two and a half million new HIV infections among African adults every year according to estimates of the United Nations Programme on AIDS (UNAIDS), and the incidence has remained about that high since then. Even under the most optimistic scenario that UNAIDS could envision in a 2005 report, the AIDS death rate in Africa will continue to rise for the coming twenty years. Optimistically, 67 million Africans will have died of AIDS by 2025. Pessimistically, the toll will be over 80 million.
The difference between UNAIDS’ optimism and pessimism for Africa is a combination of good domestic policy on the part of struggling African nations and lots and lots of foreign involvement. The most auspicious prediction for Africa would require an outlay of 200 billion dollars for improvements in health, education, and infrastructure. Depending on the week in which you are reading this article, the US might or might not currently support World Bank head Paul Wolfowitz’s proposal for a tripling of aid to Africa, or Tony Blair’s proposal for poor-nation debt relief. The US might still be tying AIDS funding to policy statements against prostitution, or might have created some new moralism-angled arm-twisting. We might have replaced condoms (in 2004 the US shipped half a billion condoms a year to Africa) with faith-based abstinence-only campaigns, the current president’s nod to “prayer and humiliation”; we might be backing condoms. We might still, as now, be devoting slightly more foreign aid to Egypt and Israel than to all of sub-Saharan Africa combined, or perhaps it will be slightly less.
AIDS has made us notice Africa. AIDS has not changed who we believe Africans are or what we imagine African people need, or perhaps deserve. To many Americans, AIDS still belongs to other people: it is a matter of their behavior, their bankrupt morals, their poor choices, or simply their bad luck. Most Americans recognize the plight of poor African Americans slightly (perhaps a bit more since Hurricane Katrina) but do not see them as us. Most of us recognize the dying in Africa but we do not think that that belongs to us, either. AIDS will end someday and, once it does, we will surely remember the dead, even the sixty or eighty or—who knows?—hundred million dead in Africa. Yet, as Susan Sontag cautioned us, while the act of remembering has moral value, “history gives us contradictory signals about the value of remembering. . . . There is simply too much injustice in the world.”
The truth of AIDS in Africa is elusive. To us in America today, AIDS remains suffused with race, with race and place, and of course irrevocably with the sexual attributes imputed to people of other races and places. Camus writes of epidemic-stricken Oran in The Plague that “this calamity was everybody’s business.” AIDS, to read the American narrative of the global epidemic, is manifestly not yet everybody’s business.