AIDS and Metaphor: Toward the Social Meaning of Epidemic Disease

AIDS and Metaphor:Toward the Social Meaning of Epidemic Disease* Allan M. Brandt (bio) no one today need be reminded of the seriousness of the aids epidemic. Although much about AIDS remains unclear, it goes without saying that AIDS is a terribly complex and tragic problem; in these early years of the epidemic, AIDS has already generated untold suffering and an enormous social crisis. Even if we could immediately end all further transmission of the virus, we would be dealing with the disease for decades to come. The numbers are truly staggering; they provide but a general sense of the full implications of the epidemic. In the United States there have already been more than 60,000 cases of AIDS; half of these individuals have died. There are currently estimated to be five to ten times as many cases of AIDS Related Complex, the early constellation of symptoms of infection with the human immunodeficiency virus (HIV). The US Public Health Service projects that more than 1 million individuals are infected with the virus.1 While the full parameters of the epidemic remain unclear, these figures are nonetheless striking. The situation in the United States represents but a significant fraction of the worldwide pandemic. The World Health Organization currently estimates that there have already been more than 100,000 cases of AIDS; perhaps as many as 20 million individuals are already infected with HIV. If projections hold true, by 1991 more than 100 million people around the globe will be infected.2 [End Page 389] Despite swift progress in identifying a causal organism, biomedical solutions to AIDS appear to be a good way off. There is currently no curative treatment and no vaccine. As we now recognize, AIDS constitutes a public-health crisis of global dimensions, a sad but powerful reminder of our relative inability to alter the nature of the biological world. HISTORY, METAPHOR, ANALOGY What does the history of disease have to tell us about this epidemic? How can we construct a useful past? These are recurrent questions as we try to assess the contemporary health crisis of AIDS. The problem, of course, is not only to find appropriate and useful analogues, but also to understand the very process by which diseases have come to be understood—their particular meaning and significance. History, of course, holds no simple truths. The historical record is not a fable with a moral spelled out at the end. Even if we could agree on a particular construction of past events—and most historians recognize how difficult this may be—it would not provide a clear guide to the future. Nevertheless, there are lessons in the way societies have responded to epidemic disease in the past that might inform and deepen our understanding of the AIDS crisis. Throughout human history, epidemic disease has constituted a natural experiment in how societies respond to disability, dependence, fear, and death. In this sense, the manner in which a society responds reveals its most fundamental cultural, social, and moral values. Disease is not merely a biological phenomenon; it is shaped by powerful behavioral, social, and political forces. Social values affect both the way we come to see and understand a particular disease and the interventions we undertake. In this view, disease is "socially constructed."3 Perhaps the most widely read and provocative recent writing on the social meaning of disease is Susan Sontag's Illness as Metaphor, first published in the New York Review of Books in 1978.4 Sontag's brilliant polemic was written long before anyone was aware of the human [End Page 390] immunodeficiency virus, although it now seems evident that this organism was already silently spreading at that time. Sontag assessed the metaphors typically associated with tuberculosis, the most fearsome disease of nineteenth-century Western societies, and cancer, until recently the most fearsome disease of the twentieth. "My point," Sontag stated directly, "is that illness is not a metaphor, and that the most truthful way of regarding illness—and the healthiest way of being ill—is one most purified of, most resistant to, metaphoric thinking."5 She argued that metaphors have powerful negative connotations which lead to the isolation and stigmatization of victims of...