But what I'm really going to write about is a sentence written by a veteran AIDS activist that Doug Ireland quotes: "AIDS was once a singular problem for urban gay white men; they basically had no other comparable burden or challenge in their life. But the disease today is inextricable from a raft of other problems of the poor, particularly the urban poor." This view is completely contradicted by a very interesting book I just read for my orals. I wrote a summary of the book, which I'll post here:
Michelle Cochrane, When AIDS Began: San Francisco and the Making of an Epidemic (Routledge, 2004)
This book argues that the medical and public health response to the AIDS epidemic has been shaped from the very beginning by assumptions that led researchers to overlook important factors, foreclose possible explanations, and in ways both concrete and abstract harm the public health. In general, “Throughout the course of the epidemic, the general tendency inherent in surveillance activities and epidemiological research was to magnify the role of gay male or (hetero)sexual intercourse in driving the HIV/AIDS epidemic and minimize the contribution of chronic urban poverty, poor public health and services, and injection-drug use and substance abuse in producing and sustaining this epidemic” (191). She wants to ask how people were diagnosed with “AIDS” and whether this blanket diagnosis tended to obscure the complexity of the epidemic’s course, and also ask what epidemiological possibilities were foreclosed rather than opened up by this fact.
She argues that the disease was socially constructed very early on as a sexually transmitted disease, in ways that obscured the presence of other factors, such as IV drug use, poverty or homelessness, or multiple other major chronic health issues in virtually all of the earliest cases of AIDS in San Francisco. She shows this by looking at the medical charts and CDC epidemiological interviews of everyone diagnosed with AIDS in 1981, showing that the likelihood of homosexual transmission was magnified, murky realities were reduced, and social factors were obscured. The sexual transmission model meant that cases with multiple factors were automatically, until the late 1980s, assumed to be cases of sexual transmission, when in fact IV drug use or other risk factors might have been relevant. She shows, strikingly, that some public health researchers actually attributed the hepatitis B, AIDS, and other sexually transmitted diseases in gay men to the 1974 decriminalization of sodomy in California. She argues that male homosexuality had been demedicalized in the early 1970s but was already far along a process of re-medicalization, through hepatitis B vaccine trials and other efforts, in the late 1970s. The hepatitis surveillance context does, I think, help explain why so many gay men thought it plausible that the government might have been responsible for introducing the virus into the population, which she does not discuss.
She shows persuasively that the construction that AIDS “first” arose among those in a “fast-track” lifestyle of “affluent and previously healthy white gay men” (190), and was later spread in a “second” epidemic to poor IV drug users, is totally wrong. She also shows that there is practically no other explanation for why this explanation came into circulation other than a core belief that gay male sexual culture was inherently hedonistic and unhealthy. The first two AIDS cases diagnosed in San Francisco were African American pediatric cases, both children of the same mother who used injection drugs. Almost all of those who presented clinically in the next two years were homeless or poor, chronically unemployed, already sick, or used lots and lots of recreational drugs – but even if there was any chance that they were gay, they were counted as cases of sexual transmission. One of her most interesting arguments is that while many of these people had moved multiple times within the city or between cities and gave multiple addresses, the city DPH distorted these cases so as to exaggerate the concentration of cases in the city’s white gay male district, especially the Castro, and to underestimate concentration in neighborhoods with lots of poverty, homelessness, and people of color; these geographical data were then used to shape future research and consequently had permanent ramifications that distort the public’s perception of what the disease actually was. “I am suggesting . . . that the epidemic began, and to a large extent remains to this day, overwhelmingly (although not exclusively) concentrated among impoverished, politically disenfranchised, marginalized inner-city populations, a population that does not ipso facto exclude homosexual/bisexual men” (57).
The book would have done better to include a more detailed discussion of the history of the process of isolating the HIV virus itself. She shows that the American and French researchers who were involved in the international dispute settled out-of-court in 1987 over who had first isolated the AIDS virus also signed an agreement literally to agree on an orthodox history of the virus’s discovery and never to cast any doubt publicly on this narrative (11-12). This material may not have been available to her.
In the first half of the book, Cochrane reconsiders all the AIDS cases diagnosed in San Francisco in 1981, looking at their medical charts and CDC and attempting to show that their cases were far more complex and murky, and that they survived much longer without treatment, than previously thought. She argues, disputing Shilts and others, that the SF Department of Public Health and the CDC were convinced from the outset that the disease was sexually transmitted and that gay male lifestyle was to blame.
And yet, at the same time, she argues that the government’s decision in 1987 to promote the idea that AIDS was likely to strike heterosexuals through sexual contact was never plausible. She says it never was an “equal opportunity disease,” that funds spent to prevent its spread among heterosexual women and white college students have been almost totally a huge waste, and that the prevention message that a condom breaking one time can give you the disease, while technically true, also was promoted for ideological reasons having to do with sexual morality and as a way to get (desperately needed) funding.
She doesn’t deny that there really is an HIV virus, but she thinks the possibility that there were multiple viruses that interacted in some way in vulnerable individuals was discounted by the construction of a tautological set of diagnostic criteria that meant that confusing cases were and still are determined to “be” “AIDS” even in the absence of important criteria. She has a problem, because she wants to argue that researchers did not hold out for long enough the possibility that social factors rather than a single “killer virus” contributed to AIDS epidemiology before the discovery of the HIV virus – and yet once there actually WAS found to be a “killer virus” this point becomes, at least for most of us, irrelevant. In general, this book would probably be better received if she were less willing to hear the claims of “AIDS dissidents” who think HIV doesn’t cause AIDS – although she would doubtless say that silencing alternative possibilities would go against her whole point.
She says that “official public health data and discourse, epidemiological research, and HIV/AIDS surveillance practices and policies collectively elided the multiplicity of social and behavioral risk factors that characterized those populations most likely to acquire the disease, instead favoring an explanation based on the random chance of being exposed just one time to a single highly infectious and fatal virus” (191).
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