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THE GREATER THREATS OF AIDS1
Not only the viral disease of body, but the historical and hysterical disease of the society
will kill us.

We Americans are afraid not only of AIDS; everything scares us to death, and that’s why we’re so cocky.  Our experience  with AIDS is not merely an infection or an affliction, but a societal furor which has nothing to do with a virus.  To understand the complex societal phenomenon we must look at several analytical levels at once, not only separately, but integrated into a whole picture.

VIRAL:  From the outset of this new disease, we recognized that it likely is caused by a virus, because of the general nature of the symptoms, their association with the development of cancers and the pattern of contagion.  The HTLV-III virus has been identified, and inquiry proceeds into other factors which allow the disease to occur.

IMMUNOLOGIC:  The  response of the human organism to exposure to the virus seems to vary.  This is like the varieties of other infectious illnesses, not unusual.  We have learned more about the immune system and white blood cells.  We have a good idea this virus disables the T-lymphocytes called "helpers" which are integral to the recognition of molecules as "friendly" or "foreign."  Without such immunologic recognition, infection and cancer can occur more easily, as well as "auto-immune disease", the body attacking its own tissues.

PSYCHOLOGIC:  We fear death, and when we know there is a disease against which we have no cure, we fear dying from it.  Confidence that we can be well seems necessary for daily living and for planning our futures.  Some noble persons acknowledge terminal disease and join with their intimates in living together more intensely even as the end approaches, sharing sadness, joy, anger and love--living until they really die.  Some others may not be dying, but respond emotionally as if they were.  The unknown gives us too many chances to set aside our living and at the same time to go about dying not at all so gracefully.

INTERPERSONAL:  Relationships can be disrupted not by microorganisms but by panic.  The tragedy of disrupted relationships comes not because of the disease, but because of the shallowness with which we live alongside one another in families, schools, work places, communities and friendships.  Modifying sexual behaviors, avoiding the sharing of needles and effective techniques for screening donated blood will avoid much infection; but scape-goating and abandoning other persons will do nothing but contaminate and impoverish our lives.

SOCIETAL:  It is accidental that the of American homosexual community has become the repository for much HTLV-III infection, but it is a painful accident for everyone in our society.  The health of our society was enhanced by some success in expanding acceptance of individual differences, to liberate us from the necessity of racial hatred and rigid gender roles.  Now the accident allows hatred of homosexuals to explode again, poorly disguised as hatred of the virus.

HISTORICAL:  If our society right now faces disruption of relationships and pain of violent hatred and discrimination, it is not necessary that all the results will be bad.  To face crisis together gives us the opportunity to gain new understanding of ourselves and take effective action.  The epidemic is not good, but adversity gives us the opportunity to grow wiser and to grow closer in community.  That will be good for the health of all.

Perhaps there are other plausible levels of analysis to add to these six, but our task is to understand, not to enumerate innumerable details.  Now let me sketch the experiences of a few real persons who are my patients to show the impact of the AIDS phenomena--not the disease but the psychological, interpersonal and societal ramifications of the panic.  Names and dates are falsified, of course, but the true personalities have been preserved.

Ralph is a 30-year-old male homosexual male who has had nonspecific symptoms for years:  swollen lymph nodes, fevers, sweats, weakness, chest pain and prolonged and recurrent sore throats.  His personal life and work were shattered as he was preoccupied with fear of the disease even before we called it AIDS.  He had consulted many clinicians seeking certainty or advice which could calm him.  Long before screening tests were developed, he had evaluation in a research center suggesting AIDS Related Complex, confirmed recently by immunologic tests (ELISA and Western blot tests).  His panic brought him close to losing his job because he could no longer function adequately, but coordination among his clinicians, participation in support groups and group therapy seem to have enhanced his personal stability.  He was offered an attractive new job, but chose a promotion in his current work instead.  He may develop AIDS, but he is living, working and growing.

Martha is the 60-year-old mother of a male homosexual.  Although I assured her there were no cases of infection in family members of AIDS victims (of which her son is not yet one), she refused to see her grandchildren until after several weeks of repeated testing.  Her relation to her grandchildren has been injured, which pains and frustrates her daughter.

Hal is a 38-year-old male homosexual who abandoned years of social and business ties in San Francisco and moved to Denver to start a new life in a setting less intensely dominated by the repercussions of AIDS (but Denver's suffering is not less intense).  His health is good.  He has not yet chosen to get screening tests (for asking the question may produce an answer for which there is no good response).  The obstacle in his beginning a new business seems to be his objectively unfounded feeling that "I will not be alive in three months."

Marjie is a 24-year-old un-promiscuous heterosexual Caucasian female who does not use drugs, has never been ill, has had no surgery or blood transfusions.  She was referred to me for counseling from a blood bank where her altruistically donated blood was found to screen weakly positive for HTLV-III antibody.  Although the blood bank knew it was almost certainly a case of false positive testing (99 per cent of the weakly positive screens are really negative tests), they told her nothing but, "You must see this doctor about something in your blood."  In our discussion of the circumstances calmly she seemed to understand and seemed a bit puzzled at my strong advice to mention the episode to absolutely no one.  (She said she would tell her mother despite my warning.)  At the subsequent visit when she came for her general routine examination and Pap smear she was uncomfortable and confused.  When I sent her across the hall to get blood drawn to check for anemia she walked away.  I called her on the phone, let her know I had a sense of why she was uncomfortable.  She listened without response.  She has not returned.

Societal levels of the panic are being discussed broadly in the press now, so I know people are aware of unusual and questionable institutional policies2 (e.g., the State Health Board declaring positive screening reportable, the military's program to screen all personnel, the ejection from class of school children who have been infected at birth), the economic impact of irrational reactions (e.g., the rapid financial ruin of many previously successful hairdressers, the decline of some restaurant and nightclub business), irrational fear of donating blood (but contamination may take place in receiving, not giving blood).  I know that homosexuals have felt fear as they have watched changes in relationships to friends, family and colleagues.

There is no question that the AIDS era will have changed our culture and society.  If we let confusion between disease and culture topple the integrity of our formal and informal institutions, we may see not only homophobia but racial hatred, rigid gender roles, generalized suspicion and hopelessness to rival that of Nazi Germany.  When afraid, we irrationally seek control in a paranoid and grandiose manner which engenders coercion and dictatorship.  This is not a result of virus or disease, but something we ourselves have chosen in the process of our history.

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1This is how I wrote the note in 1983.  Technical knowledge of AIDS has certainly expanded, but cultural and societal misunderstanding and terror have not improved, just receded from visibility.  Because we think we have some treatment for the disease, as a society we no longer act panicked, but are we paying attention to AIDS in Africa, in the rest of the world?  Are we willing to help there?  Does our cultural illness flare up with hatred every time we face what we perceive as a threat or crisis?

2 “Questionable policies” because at that time we had not yet addressed the problem of balancing privacy versus the need for screening, nor (as the examples indicate) did we have really reliable screening.  AIDS has had many victims; at that time they died for the most part; but societal panic had many victims also, and many of them died as a result.

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