Study Guide #13, 12/06-12/08: Public Health Revisited Treichler, Paula. “AIDS, Homophobia, and Biomedical Discourse: An Epidemic of Signification,” Cultural Studies 1 (October 1987) 263-305. Specter, Michael. “Higher Risk.” New Yorker 81 (23 May 2005): web version. Jones, D.S., and A.M. Brandt. “AIDS, Historical.” In Encyclopedia of Microbiology, 2nd ed., ed. Joshua Lederberg, vol. 1. San Diego: Academic Press, 2000. pp. 104-115 Brandt, Allan M. “The Cigarette, Risk, and American Culture.” Daedalus 119:4 (Fall 1990): 155-176. In the week on Therapeutic Revolutions, we read two articles that examined public health controversies in the early years of germ theory: the debate about whether or not tuberculosis should be a reportable disease (i.e. whether doctors must report all diagnosed patients to government public health authorities), and the debates about Mary Mallon and other ‘healthy carriers.’ The 1880s to 1910s were a time when germ theory was new, when doctors were still not completely convinced of its relevance, and when bias (whether sexual, ethnic, racial) was ubiquitous in medicine. Today we return to those questions by focusing at a more recent episode, the history of HIV/AIDS. The status of medicine and the medical profession has changed immensely since 1880. By 1980, medicine had become prestigious and powerful. Disease theories were backed by sophisticated scientific knowledge and technology. Infectious diseases had been “conquered”: antibiotics controlled bacterial infections, immunizations controlled serious viral infections, smallpox had been eradicated, and so on. It was a time of extreme confidence, and supposedly a time of scientific objectivity. As you will see in the readings, both the confidence and the faith in objectivity vanished with the emergence of HIV. Confusion, uncertainty, bias, and stigmatization dominated HIV in the 1980s, and continue (possibly to a lesser extent, at least in the US?) today. During this time, a new disease concept began to take center stage: risk. Doctors had always thought about risk factors for disease, but in the 19th and early 20th century, the focus was on the more concrete task of diagnosis and treatment. After World War II, however, concern with hypertension, heart disease, cancer, and cigarette smoking focused researchers’ interest on risk. Is hypertension a disease, or a risk factor for disease? Is smoking dangerous? What do you have to do to prove that smoking causes cancer? If an activity increases peoples’ risk of disease, should it be banned? Advised against? Taxed? Questions of risk,and responsibility, dominated discussions of public health in the late 20th century, especially with HIV and cigarettes. Jones & Brandt, “AIDS, Historical”: Although encyclopedia articles can be a confining genre, this article contains a useful overview of the disease and its history. Although you should focus on the historical sections (pp. 105-), the section on pathophysiology and viral origins provides useful background. Pay attention to how the earliest cases were recognized. How did knowledge of the initial risk groups affect research about HIV? Suppose that Uganda had had a sophisticated medical system and had diagnosed the epidemic among heterosexuals in the 1970s: would this have altered the history of the disease? Why did HIV produce such fear in the 1980s? Would people have been as frightened of the epidemic had it started in 1900? Could it have started in 1900? Would the epidemic have spread as quickly? Did scientists have the technology needed to recognize it? Did the development of the first screening test in 1985 increase or decrease fear and controversy? Why did the US government refuse to implement effective HIV control programs? Why does it continue to refuse? How has HAART changed HIV? In what ways has AIDS and AIDS treatment differed in developing countries and the United States? Is HIV in Africa a public health threat to the United States? Can scientific progress increase social injustice? Treichler, “Epidemic of Signification”: Paula Treichler, a philosopher and linguist, has been a leading scholar of HIV since the epidemic began (www.comm.uiuc.edu/icr/faculty/profiles/Paula_Treichler.html). This article is one of her most interesting and influential pieces; it deserves to be read carefully. For our purposes, it is simultaneously a sophisticated analysis of disease meanings, and a glimpse into perceptions of AIDS in 1987. Don’t get scared off by some of the linguistic theory and lingo: if you read the opening pages carefully you will understand her arguments and appreciate their importance. Why did AIDS spawn an “epidemic of meanings”? Do you think that other diseases are equally productive, or is there something unique about HIV? Why are these meanings relevant? She gives many examples, for instance showing how the link between AIDS and homosexuality affected disease theories, knowledge production (e.g. the questions asked by CDC researchers), patient experience, health policy, etc. Her list of AIDS descriptions (pp. 264-265) is especially revealing: it shows what people thought about the disease at the outset. Some were meant in jest, others were deadly serious (#2 is from Jesse Helms; #6 and #37 from Robert Gallo; #10-#14 circulated as popular conspiracy theories into the 1990s). Try to understand the fears, prejudices, etc. behind the different statements.Specter, “Higher Risk”: Michael Specter (www.michaelspecter.com/index.html), a reporter for the New Yorker, has published many articles about HIV and AIDS. In this article (from just last May), he described a growing “syndemic” of crystal methamphetamine use and HIV among gay men, especially in San Francisco in New York City. Why does the HIV epidemic persist in the US despite effective treatment? What impact has HIV had on the gay community in the US? What is it about crystal methamphetamine that makes it so appealing for the people he describes? Why is there a dangerous synergy between crystal meth and on-line ‘dating’ services? He makes a series of specific claims about how crystal methamphetamine increases risk of HIV transmission -- are these credible claims? How could you tell? What public health efforts are being made to contain this resurgent epidemic? To see one example of a targeted health campaign, check out the homepage