The Definition and Control of Disease—An Introduction

Abstract

The Definition and Control of Disease—An Introduction Charles E. Rosenberg (bio) aids has reminded us of some very old truths, truths most americans had managed to forget during the past four decades. Epidemic infectious disease is not simply a historical phenomenon—or one limited like famine to the nonwhite in remote continents. By the end of the 1970s, most Americans had come to regard themselves as no longer at risk; infectious disease was almost by definition amenable to medical intervention. Not since the last severe polio threats more than a quarter century ago has the United States experienced the collective fear of epidemic disease.1 AIDS has helped us remember some other things as well. One is the way in which epidemic disease mobilizes widespread social response to the same stimulus; because AIDS was new to the 1980s that response was particularly intense and illuminating. Our reactions have underlined both our common humanity and America's cultural and institutional diversity. Epidemics serve as natural sampling devices, mirrors held up to society in which more general patterns of social values and attitudes appear in sharp relief. AIDS has demonstrated as well the way in which epidemics take place at a number of levels—biological event, social perception, collective response, and, finally, the individual, the existential and moral. Yet these several aspects of an epidemic can be disaggregated only for the purpose of analysis, for they are intricately linked and constantly interactive. Each disease entity, as a social phenomenon, is a uniquely configured cluster of [End Page 301] events and responses in both the biological and social spheres. AIDS reminds us of not only the multiple levels at which disease exists, but the urgent need to understand the interactions between these constituent aspects of the phenomenon we call an epidemic. The following papers focus differentially, in fact, on those levels, Lederberg emphasizing the biological, Foege organized public policy, Nelkin and Gilman the individual and attitudinal. Finally, AIDS has made it clear that we are not masters of life; there are limits built not only into humankind's genetic makeup but into our changing ecological relationship with the rest of the world and the multiplicity of organisms that inhabit it. We tend to think of ills as either fundamentally biological and unambiguous in their medical identity (rooted in a well-understood biopathological mechanism) or as value-laden and problematic in their relationship to medical models and medical authority. AIDS occupies a position at both ends of that spectrum; it is an affect-laden occasion for the blaming of victims while, at the same time, it is the consequence of a particular and extraordinarily deadly biological mechanism.2 This new pestilence can hardly be considered an arbitrary exercise in the labeling of deviance. It is a plague in the classic sense, allied to such predecessors as bubonic plague, yellow fever, and cholera. Joshua Lederberg's essay construes AIDS as pathobiological process and humankind as animal, subject to the ultimately unpredictable vagaries of its physical and biological environment. By invoking the logically linked contributions of Darwin and Pasteur, Lederberg seeks to place his argument in a cosmic framework, in which man's cognitive capacities are but one variable in a complex, ever-changing, and unpredictable universe. When he alludes to the microbiological events that have taken place in his laboratory test tube, Lederberg refers metaphorically to man's place on earth—our particular test tube, in which human population has increased rapidly and perhaps ominously in the past century. Dorothy Nelkin and Sander Gilman focus on a rather different level: the way in which men and women have tended to reduce [End Page 302] their sense of vulnerability in times of plague by defining others as the ailment's appropriate and likely victims—creating reassuring frameworks in which to control and disarm otherwise disconcerting realities. Cultural values and social location have always provided the materials for self-serving constructions of epidemiological risk. The poor, the alien, the sinner have all served as convenient objects for such stigmatizing speculations. William Foege's essay emphasizes a rather more public and institutionalized response to epidemic disease. Public health is a contested terrain in which objective data interact...