AIDS and Ebola: nineteenth-century paradigms of disease, or charting new territory?

The world has struggled with many epidemics over its history that have caused widespread fear and abruptly altered the fate of societies. Leading nations recently placed historians of nineteenth century epidemics into the limelight to deduce explanatory models of how society dealt with previous threats (Berridge and Strong 131). This essay will assess how far the two epidemics of AIDs and Ebola that have taken place in recent decades revisit paradigms of nineteenth century disease. It argues that whilst there is inevitably a modern twist on epidemics and the experience of living with a disease, fundamentally there is a broad pattern of repeat in the way in which AIDs and Ebola have been dealt with.

The Centrality of Poverty

The first paradigm of the nineteenth century experience of disease revisited in the AIDS crisis is the centrality of poverty in epidemics. In late nineteenth century Europe, whilst cholera could and to some degree did impact the upper echelons of society, it disproportionately afflicted the poor in most outbreaks (Evans “Epidemics and Revolutions” 130). Those who were more economically viable could either flee the infected areas, or were less likely to come into contact with contaminated water due to their more privileged and sanitary lifestyle. Conversely, the poor engaged in behaviours that left them more at risk such as the use of infected water supplies and overcrowded housing conditions which were believed to predispose urban populations to cholera. This associated the disease with poor economic conditions and restricted the options of the lower classes. In the 1892 outbreak in Hamburg, statistics on key socioeconomic indicators in 20 districts showed that economically independent households with bathrooms (r=-0.69) and servants (r=-0.71) demonstrated strong negative correlations between cholera mortality and wealth (Evans “Death in Hamburg” 591); the fewer indicators of a high economic status a person had the higher their likelihood of dying from cholera. This is an example of what is termed structural violence by anthropologist and physician Paul Farmer, who argues that the structure in which you live determines to what extent an individual is put at risk, and that those living in poverty are systematically underprivileged (Farmer “Pathologies of Power”).

This is still evident in the case of AIDS and demonstrates how broad patterns of repeat remain present in epidemics. In the United States death by HIV is often governed by poverty. Anthropologist Martha Ward attributes increased risk factors in women with persistent social inequality, maintaining that poverty is the primary and determining component to the risk of HIV (Farmer “AIDS and Accusation” 44) and to overlook statistics on socioeconomic status and concentrate on ethnicity alone is not sufficient. Although dated 2003, I argue that this statement remains accurate today. In a 2015 HIV Surveillance Report published by the U.S Centre for Disease Control (CDC) the following statistics were released: of the 6,120 heterosexual women diagnosed with HIV in 2015, 4,142 (67.6%) were of African America origin compared with 968 (15.8%) white Americans. When you correlate this respectively with US poverty statistics, 22% of Americans deemed to be living in poverty were black and 8.8% white. This demonstrates a strong relationship between ethnicity, poverty and incidence of HIV, and is confirmed in a separate CDC study investigating whether impoverished areas of the U.S were experiencing a generalised HIV epidemic. Conducted over 25 cities for a period of a year, the study concluded that the HIV prevalence rate at 2.1% in urban poverty areas was very high and exceeded the 1% cut-off that defines a generalised HIV epidemic. These rates were inversely related to socioeconomic status (SES) – the lower the SES, the greater the rate (Denning and DiNenno) which shows the same trend as the nineteenth century cholera epidemic in Hamburg. In this study, ethnicity did not significantly affect the HIV prevalence rates in urban poverty areas which confirms Ward’s argument that it is destitution that governs the incidence of HIV. In a New Society article historian Roy Porter blames a lack of cohesion between state departments for the slow U.S response to AIDS. He argues that the state wouldn’t necessarily have dealt with the epidemic any better if it had struck middle class white people first. However I refute this theory on the grounds that the evidence examined thus far indicates that in actuality the problem stems from the state itself and the inescapable cycle of deprivation it exposes the lower classes to. The poor were victims far before the onset of the AIDS epidemic. The fact that diseases repeatedly afflict lower class citizens in disproportionately high numbers is due to discriminatory social conditions. As the CDC reports show, it was statistically unlikely to cause a generalised epidemic in persons with a high socioeconomic status, therefore Porter’s reference to the ‘slow response’ of the U.S government does not address the point of the problem.

Suffering is undoubtedly present in the West but the stronghold of AIDS is primarily among the worlds most impoverished. The centrality of poverty is exacerbated when underdeveloped nations are examined. Since the first epidemic of AIDS in the 1970’s in the Democratic Republic of the Congo, by the year 2000, 95 per cent of the 1 million deaths a year were in developing countries and particularly in sub-Saharan Africa (Chakrabarti “Global Poverty and Disease Lecture”). Although biologically the disease is the same, economic differences have led to hugely distinctive experiences of AIDS. HIV researcher David Serwadda stated that upon trying to initially determine the disease that his team “could not connect a disease in white, homosexual males in San Francisco to the thing we were staring at in Uganda” (Chakrabarti “Global Poverty and Disease Lecture”). Extreme poverty in developing nations has led to an African encounter with HIV that sees predominantly heterosexual young adults suffer with the disease. In a study of rural Malawians in 2007, Mike Mathambo Mtikia concludes that circular migration as a result of livelihood struggles is typical of young men throughout Africa who do not operate under a nuclear family system and engage in AIDS-risky sexual behaviour that is associated with the spread of HIV (2455). This behaviour made necessary by poverty maintains the argument of structural violence. Economically viable parts of the world such as the U.S had made AIDS more manageable by the 1990’s yet it continues to devastate underdeveloped regions. However in all countries, since the nineteenth century globalisation has created interdependencies and inequalities that have resulted in parallel linkages between the lives of the poor across the world. Those at the bottom of inegalitarian societies suffered the effects of epidemics in disproportionately high numbers in the nineteenth century, and unfortunately continue to do so today.

The Symbol of Blame

Social reactions to world epidemics are characterised by the creation of a framework which legitimates and reveals moral assumptions in a society. Response to epidemics has always been constrained by pre-existing constitutional values (Rosenburg 12) which manifest themselves into a symbol of blame whereby a particular population becomes associated with a disease as a result of their identity or behaviours. An American tendency to blame victims is evident in the 1892 typhus outbreak in New York, and in the stigma surrounding both Haitians and homosexual males in the recent AIDS epidemic. This shows how nineteenth century paradigms are being revisited in patterns of blame.

In an era of mass immigration to the U.S from Eastern Europe, when typhus erupted in epidemic proportions in the Jewish Quarter of the Lower East Side of New York City in 1892 (Markel 14), the blame for this ‘foreign’ disease quickly fell on the wave of mass immigrants coming from Eastern Europe. Synonymous with filth and disease, social revulsion towards poverty stricken Russian Jews escalated and it was widely acknowledged that they were a major public health danger to New York. This attribution of the aetiology of a disease with a particular group in society is revisited in the case of Haitians during the early years of the AIDS epidemic. Stereotypes and cultural narratives of both the native Haitian population and populations across America caused huge moral panic as in nineteenth century New York. In the 1980’s Haitians suffered from a triple minority status that increased their susceptibility to blame – they were black, foreign and French speaking (Farmer “AIDS and Accusation” 208). This is an example of what historian Alan Kraut terms ‘medicalised nativism’ – the amplified suspicion of a population associated with an epidemic which leads to their identity being attributed to disease causation. What should be taken into account when considering these historians viewpoints is that undoubtedly there is a high prevalence of the disease in the afflicted group. Whilst a culture of victim blaming should not be condoned, as Yale professor Sherwin B. Nuland claims in a 1997 New Republic article, it can be a case of well-justified concern when you consider that for instance in the case of the aforementioned typhus outbreak in New York there were few victims that were not of Eastern Jewish origin. Similarly, in a 2016 Nature article, phylogenetic analysis strongly supported the initial introduction of the HIV subtype B lineage into New York from Haiti estimated between the years of 1963-1971 (Worobey 100). However it is the popular tendency to attribute the origin to the individuals affected, rather than acknowledgement of a pathogenic causative agent despite medical knowledge, that is shown in both nineteenth century and modern day epidemics.

This pattern of blame for AIDS within the U.S also targets the male homosexual community. Although there was an increasing social movement decriminalising homosexuality, general attitudes derived from the nearly universal presence of homophobia in American culture (Lang 175) used AIDS as a means to reinforce discrimination. Even the medical community found it hard to abandon early assumptions about the disease and contributed to its depiction as the gay plague – in May 1982 the New York Times published an article that repeatedly referred to the condition as ‘Gay Related Immunodeficiency’ (Wald “The Columbus of AIDS” 222). AIDS represented a microbial challenge that many developing nations had not expected to face in the twentieth century when serious epidemic health dangers were no longer considered a threat, and the reversion back to the blame of a stigmatised minority is an echo of the nineteenth century experience of disease. In all these examples there is an assertion that human agency is responsible for the transmission of disease – often this need to blame the victim stems from a lack of understanding. Despite significant evidence that HIV is not casually transmitted, there has been insufficient public reassurance to reduce cultural fears (Brandt 38). Where modern epidemics should begin to diverge from the broad patterns of blame that we have seen in previous centuries is the use of scientific knowledge to educate communities and tackle stigmas. A medical standpoint made accessible to general populations would allow the breakdown of oversimplified narratives that have blamed the epidemic on the victims for so long.

The Political Role of Quarantine

When discussing the paradigms of modern epidemics in relation to the nineteenth century there is a surprising continuity of the implementation of quarantine. In 1832, 1849 and 1866 the U.S was devastated by epidemic episodes of cholera as a result of waves of migrants travelling from Europe, India and the Middle East (Markel 87). Heavy debates over miasmatic theories characterised all cholera epidemics, but the popular perception in America was that cholera was a contagious disease of foreign origin that the U.S needed to protect itself against. As seen in the typhus epidemic already discussed, Russian Jews became the readily accepted vector of cholera and all ships carrying immigrants were quarantined for a 20-day period (Markel 97). Most significantly, this policy did not apply to passengers on the same ships that were not members of the steerage class but had travelled from the same infected ports. This indicates that the motives behind quarantine enforcement were not based on the bacteriological diagnosis of cholera as much as they were on justification of immigration fears. A defence and security analysis report was published in 2015 to identify measures that American presidents have utilised from as early as the seventeenth century to protect against epidemics. It stated that for centuries U.S leaders have imposed the isolation or quarantining of persons thought to host dangerous disease in the event of an epidemic abroad (Totten 203). This knee-jerk reaction of imposing quarantine out of fear is still being reverted back to in the Ebola epidemic.

As recently as 2014, asymptomatic individuals returning to the U.S from humanitarian work in Western Africa who had not necessarily come into contact with the Ebola virus were isolated in the name of what President Barack Obama declared an ‘urgent national security issue’. There is little doubt that contagions are a critical governmental interest, but the national quarantine policies were not scientifically justified; Ebola has been found to be highly deadly but not highly infectious - there is a correlation between viral load in bodily fluids and infectiousness. Whilst fears of epidemic outbreaks of disease are legitimate, in the case of Ebola the reaction from Obama in regards to America was disproportionate. When their advanced health care infrastructure is considered the realistic likelihood of an Ebola outbreak was almost non-existent. The introduction of quarantine control measures potentially negatively impacted those in the global community suffering from epidemics as it provided a disincentive for humanitarian health workers to travel to the heart of the epidemic for fear of isolation on their return. An American Civil Liberties Union (ACLU) report investigated the response of the U.S health department in the recent epidemic and concluded that the quarantine policies were not based on the decades of scientific research available to us, but a reversion to ineffective measures motivated by misinformation and in the case of Ebola unwarranted fear (4). In a post-Koch era when bacteriological science is widely understood and miasma debates no longer dominate medical science there should be no need for ineffective control measures. Yet the report also highlights how we are in fact beginning to chart new territories in the fight against epidemic diseases; publication in 2015 when the epidemic was still ongoing is an example of what Rosenburg argues makes recent epidemics post-modern in the self-conscious and effective detachment with which we regard them (11). We now have an ability to reflect on diseases as they unfold which has allowed for a new consciousness with regard to individual rights and experiences. The aim of the report to investigate the incursions on individual freedom of the humanitarian workers is evidence that society is now aware of individual rights, and legal systems provide a means by which to enforce these. Kaci Hickox, a nurse quarantined at a New Jersey hospital on her return from West Africa, engaged in a legal dispute in 2015 with Governor Chris Christie on the basis that the state had no medical, epidemiological or legal grounds on which to hold her. Her success illustrates that we are making progress in ensuring civil rights and overcoming the reversion to policies established out of fear.

The implementation of quarantine at the U.S border in the case of Ebola highlights another potential likeness with nineteenth century epidemics. As Joel Achenbach concludes in a 2016 Washington Post article ‘Africa’s Ebola problem is now America’s Ebola problem’ - fear of it escaping the continent and surfacing in the West had finally attracted international attention. Intervention from America in epidemics taking place across the globe is in response to a national threat and in the interests of protecting themselves. It is a pattern of repeat seen when the U.S became concerned with the nineteenth century cholera epidemic only when it became feasible that the rapidly escalating outbreak in continental Europe could reach their shores (Markel 87). Comparably, hysteria was only generated in America from September 2014 when the diagnosis of Ebola on U.S soil was announced (Totten 200) – nearly a year on from the first cases of Ebola in West Africa that caused significant mortality rates from December 2013. These threats have intensified in the age of global travel that has facilitated transmission across international borders, and as Barack Obama stated at the Global Health Agenda Security summit in September 2014, ‘nobody is that isolated anymore’. Where the epidemic somewhat diverges from the nineteenth century is the humanitarian aid given to developing countries with the most significant outbreaks. The response to Ebola could not have been strengthened without international charity like government run USAID which, even if given in self-interest to prevent transmission from the epicentre of the disease, shows distinct advancement in the response of the West. An independent Lens documentary shows Liberian city Monrovia during the height of the Ebola outbreak and stresses the importance of the international community strengthening public health infrastructure in underdeveloped nations to address these outbreaks of HIV and Ebola that have become endemic.

This essay has attempted to demonstrate that broad patterns of repeat exist in the way in which society has dealt with epidemics in recent decades. Experiences with epidemics have followed a framework by which the poor are disproportionately likely to suffer under systemic structural violence, and then as victims to be blamed in the aetiology of a disease often characterised by fear and a lack of understanding. In the pursuit of explanatory models with an element of predictability, quarantine has been reverted back to for centuries. These control measures have been implemented in the U.S when disease threatened their borders in the cases of both cholera in the nineteenth and Ebola in the twenty first centuries. What cannot be ignored when discussing the nature of past and present epidemics is that both AIDs and Ebola undoubtedly chart some new territories. The scope of modern medicine in some areas of the world has allowed for disease to be brought under relative control and a bigger sense of moral obligation and individual rights has introduced humanitarian aid and legal grounds to how we deal with disease. While there are inevitable distinctions in the way we respond to contagions as a result of progressions in society, modern epidemics are marked by the continuity of nineteenth century paradigms of disease and AIDS and Ebola are in many ways a traditional phenomenon.

Works Cited: References for Further Reading

Achenbach, Joel. "Paul Farmer On Ebola." The Washington Post, 2014.

Berridge, Virginia, and Strong, Phillip. "AIDS And The Relevance Of History." Social History Of Medicine, vol 4, no. 1, 1991, pp. 129-138. Oxford University Press (OUP).

Brandt, A M. "AIDS In Historical Perspective: Four Lessons From The History Of Sexually Transmitted Diseases.." American Journal Of Public Health, vol 78, no. 4, 1988, pp. 367-371. American Public Health Association.

Chakrabarti, Pratik. Medicine and Empire : 1600-1960, Palgrave Macmillan, 2013.

Chakrabarti, Pratik. "Global Poverty and Disease Lecture." 2017.

Denning, Paul, and Elizabeth DiNenno. "Economically Disadvantaged | HIV By Group | HIV/AIDS | CDC." Cdc.Gov, 2017,

Evans, Richard J. “Epidemics and Revolutions: Cholera in Nineteenth-Century Europe.” Past & Present, no. 120, 1988, pp. 123–146. JSTOR,

Evans, Richard J. Death In Hamburg, p. 591 Table 14. New York, Penguin Books, 2005.

Farmer, Paul. AIDS And Accusation. Berkeley, University Of California Press, 1993.

Farmer, Paul, and Amartya Sen. Pathologies Of Power. Berkeley, London, University Of California Press, 2003. 

"INDEPENDENT LENS | In The Shadow Of Ebola | PBS." Youtube, 2017,

Johnson, Alex. "Kaci Hickox, Maine Nurse Quarantined In Ebola Scare, Sues New Jersey Gov. Chris Christie." 

NBC News, 2015, Washington Post.

Lang, Norris G. "Sex, Politics And Guilt: A Study Of Homophobia And The AIDS Phenomenon." Culture And AIDS, pp. 169-182. Douglas A Feldman, Praeger Publishers, New York, 1990.

Markel, Howard.. Quarantine!: East European Jewish immigrants and the New York City epidemics of 1892. Baltimore, Md. : Johns Hopkins University Press, 1999, c1997.

Mtika, Mike Mathambo. "Political Economy, Labor Migration, And The AIDS Epidemic In Rural Malawi." Social Science & Medicine, vol 64, no. 12, 2007, pp. 2454-2463. Elsevier BV.

Nuland, Sherwin. "Hate In The Time Of Cholera." New Republic, 2017,

Porter, Roy. “Epidemic Of Fear.” New Society, 1988

"Remarks By The President At Global Health Security Agenda Summit." Whitehouse.Gov, 2017,

"Report: Fear, Politics, And Ebola." American Civil Liberties Union,

Rosenberg, Charles E. “What Is an Epidemic? AIDS in Historical Perspective.” Daedalus, vol. 118, no. 2, 1989, pp. 1–17. JSTOR, JSTOR,

Totten, Robbie J. "Epidemics, National Security, And US Immigration Policy." Defense & Security Analysis, vol 31, no. 3, 2015, pp. 199-212. Informa UK Limited, doi:10.1080/14751798.2015.1056940.

"U.S. Poverty Statistics." Federal Safety Net, 2017,

Wald, Priscilla. “The Columbus of AIDS.” Contagious Cultures, Carriers, and the Outbreak Narrative. Durham, N.C., Duke University Press, 2008.

"Women | Gender | HIV By Group | HIV/AIDS | CDC." Cdc.Gov, 2017,

Worobey, Michael et al. "1970S And 'Patient 0' HIV-1 Genomes Illuminate Early HIV/AIDS History In North America." Nature, vol 539, 2016, pp. 98-100. doi:10.1038/nature19827.

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