How should we understand the fear and fascination elicited by the accounts of communicable disease outbreaks that proliferated, following the emergence of HIV, in scientific publications and the mainstream media? The repetition of particular characters, images, and story lines-of Patients Zero and superspreaders, hot zones and tenacious microbes-produced a formulaic narrative as they circulated through the media and were amplified in popular fiction and film. The "outbreak narrative" begins with an emerging infection, follows it through the global networks of contact, and ends with its containment. Priscilla Wald returns to the early years of microbiology and "Typhoid Mary," to the advent of virology and Cold War "alien" infiltration, and to body snatchers and the HIV/AIDS pandemic to show how evolving ideas about contagion and horror coalesced in the outbreak narrative. These stories of disease emergence have consequences. They can affect survival rates, contagion routes, and economies. They can promote or mitigate the stigmatizing of individuals, groups, locales, behaviors, and lifestyles. Contagious shows how the stories we tell circumscribe our thinking about global health and human interactions as the world imagines-or refuses to imagine-the next Great Plague.
About the Author:
Priscilla Wald is Professor of English at Duke University
About the Author
Priscilla Wald is Professor of English at Duke University. She is the author of Constituting Americans: Cultural Anxiety and Narrative Form and the editor of the journal American Literature, both also published by Duke University Press.
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ContagiousCULTURES, CARRIERS, AND THE OUTBREAK NARRATIVE
By Priscilla Wald
Duke University PressCopyright © 2008 Duke University Press
All right reserved.
Chapter OneImagined Immunities
THE EPIDEMIOLOGY OF BELONGING
The image of the desolate African camp decimated by an unknown hemorrhagic virus was already a stock scene of journalism and fiction when Wolfgang Petersen's film Outbreak opened with it in 1995. Journalistic photographs and accounts and novelistic depictions had begun to burn it into the American collective consciousness, as they marketed and managed the scientific concern about emerging infections. Petersen's film combined that with many other stock images to dramatize the outbreak story and facilitate its emergence in popular culture. It offered the audience the visceral experience of the graphic description-and the particular horror-of a person's being liquefied by a hemorrhagic virus. And it rehearsed a scenario in which the outbreak of a horrific disease could travel the routes of a global economy to make a small California town almost (but not quite) as expendable to the U.S. military as an African camp-its inhabitants almost becoming, in the icy words of Donald Sutherland's marvelously sinister character, General McClintock, acceptable "casualties of war."
The credits open with a quotation from Joshua Lederberg calling viruses "the single biggest threat to man's continued dominance on the planet." The epigraph from Lederberg, a geneticist and Nobel Laureate, conferred the sanction of science on the formulaic story about how an Ebola-like hemorrhagic virus might chart a course through the global village from Zaire to Boston and California, and it helped to make the film part of the alarm that Lederberg and his colleagues sought to sound at the waning of the twentieth century. In the early years of the Cold War the U.S. military had treated anticipated epidemics, which they feared would follow a germ-warfare attack, as a national priority, but subsequent decades had dulled that threat. The miracle of antibiotics and other medical victories (such as the eradication of naturally occurring smallpox in 1977) seemed to have made infectious disease a relatively minor inconvenience in the global North. In the early 1990s Donald A. (D. A.) Henderson, who had spear-headed the smallpox-eradication program for the World Health Organization, somberly recalled that in 1969 the Surgeon General had called the problem of infectious disease in the United States "marginal" in a speech he delivered at the Johns Hopkins University. But by the 1990s, HIV and other untreatable communicable diseases had shown the optimism to be premature.
Richard M. Krause of the National Institutes of Health (NIH) had heralded the problem of these infections in his 1981 book, The Restless Tide: The Persistent Challenge of the Microbial World. But the threat posed by viral epidemics was not widely acknowledged until a 1989 conference, held at the end of the decade in which HIV had compelled international attention. The conference assembled prominent infectious- and tropical-disease specialists (and one medical historian) to address the outbreak of numerous newly identified or resurfacing communicable diseases. With the term emerging infections, they connected those outbreaks, defining a phenomenon for which they then sought a comprehensive explanation. Co-sponsored by the National Institute of Allergy and Infectious Disease, Rockefeller University, and the Fogarty International Center, the conference spawned committees and publications that addressed the topic, including the Institute of Medicine's 1992 report Emerging Infections (of which Lederberg was a coeditor) and a 1993 collection of essays from the conference, Emerging Viruses. Emerging infections, the participants concluded, were the consequence of globalization. An expanding human population worldwide meant that human beings were living and working in previously uninhabited places and coming into contact with unfamiliar or dormant microbes, which in turn globe-trotted by hitching rides in hosts-human, animal, and insect-using the variety of transportation networks that constitute the global village.
Those networks also helped to produce social and political transformations that were of particular interest to social scientists. Studies of political affiliation, especially of the nation, proliferated, turning critical attention to the forms of belonging that had dominated the modern world and speculating about their fate. Belonging took a biological turn in a cluster of studies penned in the 1990s by scientists who addressed the role of communicable disease in shaping human migrations, populations, and communities. Such works as the biologist Christopher Wills's Yellow Fever, Black Goddess: The Coevolution of People and Plagues (1996), the immunobiologist Michael B. A. Oldstone's Viruses, Plagues, and History (1998), and the physiologist Jared Diamond's bestselling Guns, Germs and Steel: The Fates of Human Societies (1997) put the relationship between disease emergence and demographic change in historical context.
Meanwhile, the mainstream media, fiction, and film were bringing the epidemiological sensation of disease emergence to a broad public. Outbreak was but one of many fictional and nonfictional accounts of emerging-disease outbreaks that dramatized the scenarios that infectious- and tropical-disease specialists were debating in their meetings and publications. Nonfiction bestsellers-such as Richard Preston's 1994 The Hot Zone, which first appeared as a New Yorker article entitled "Crisis in the Hot Zone" in 1992, and Laurie Garrett's 1994 The Coming Plague-heralded the danger of these species-threatening events, and they were quickly supplemented by novels and films, including Carriers (Patrick Lynch, 1995), Contagion (Robin Cook, 1995), The Blood Artists (Chuck Hogan, 1998), Twelve Monkeys (dir. Terry Gilliam, 1995), The Stand (dir. Mike Garris, 1994), and Outbreak. D. A. Henderson believed that the outbreaks themselves served "usefully to disturb our ill-founded complacency about infectious diseases," and it is no surprise that Lederberg lent his words to Petersen's film. Lederberg and his colleagues welcomed almost any means of calling attention to what they saw as an impending disaster; Lederberg had in fact leaked the story that inspired Preston to write The Hot Zone. Scientists and science writers who had seen the effects of hemorrhagic viruses were especially eager to convey the magnitude of the problem. Even at their most sensational, fiction and film provided a way to educate the public about the threat and the science of these deadly infections.
Fictional accounts of outbreaks did more than reflect and convey the lessons of science; they also supplied some of the most common points of reference, which influenced social transformation and disease emergence in their own right. One of the most commonly evoked and formative images of disease emergence is in fact drawn from a novel that preceded the Washington conference by two decades. Michael Crichton's 1969 novel, The Andromeda Strain, which was made into a film in 1971, tells the story of mysterious microbes that are brought back to Earth on a space probe and wipe out most of a town in the Arizona desert, killing either instantly or indirectly (through madness) and leaving only two survivors. The unfamiliar microbes turn out to be common terrestrial organisms mutated by extraterrestrial exposure: the lethal and mysterious effect of space exploration. The microbes dissipate on their own, and, in fact, the incorrect assumptions and dangerous fail-safes nearly lead the scientists to create the apocalypse they had been trying to prevent.
The term "Andromeda strain" has become shorthand for sudden devastation caused by mysterious microbes and mismanagement: a clash of ecosystems with cataclysmic consequences on a global scale. It invokes the terror of a species-threatening event and transforms the dangerous terrain of space exploration into the perilous landscape of global development. Laurie Garrett reaches for this common referent in The Coming Plague to describe the foreboding articulated at the 1989 conference: "The Andromeda strain nearly surfaced in Africa in the form of Ebola virus; megacities were arising in the developing world, creating niches from which 'virtually anything might arise'; rain forests were being destroyed, forcing disease-carrying animals and insects into areas of human habitation and raising the very real possibility that lethal, mysterious microbes would, for the first time, infect humanity on a large scale and imperil the survival of the human race." Garrett is an important presence in my study not only because her bestselling book was one of the first and most responsible journalistic sources to bring the problem of disease emergence to a mainstream audience, but also because The Coming Plague exemplifies how a conscientious, informed, compassionate account of disease emergence can be complicated by language and images that tell competing stories. Garrett uses the Andromeda strain, for example, to dramatize the threat of rapid and careless development and the failure to consider the consequences of human encroachment on "primordial" ecosystems that harbor unfamiliar and deadly microbes. She offers as the only "wonderful news in the emerging disease story" the observation that "nearly all outbreaks and epidemics are the fault of our own species-of human beings-not of the microbes." Human behavior can change the circumstances that "imperil the survival of the human race."
Yet Garrett's rhetoric undermines her analysis. Throughout The Coming Plague, animated, "primordial" microbes wage war on a besieged humanity. They turn the "African" landscape primitive, recasting the effects of poverty as a temporal lag (as in the sars photos that juxtaposed the Hong Kong airport with a Guangzhou duck pen). Garrett's use of the passive construction ("megacities were arising"; "rain forests were being destroyed") suggests mysterious, transformative forces beyond the reach of human agency. The developing outbreak narrative that she helped to produce casts "Africa" as an epidemiological ground zero, otherworldly (literally alien), a primordial stew out of which "virtually anything might arise." Although Lyme disease could be equally subject to Garrett's analysis, and appears in the litany of emerging infections in the scientific literature, Lyme, Connecticut, is not, for Garrett or her audience, a place in which virtually anything might arise. Even accounts of the Four Corners outbreak of the hantavirus, which can be as lethal as Ebola (and which Garrett treats in The Coming Plague), did not evoke the Andromeda strain despite its geographical proximity to Crichton's setting (in the Arizona desert). Garrett unwittingly infuses her socioeconomic analysis of disease emergence with the distorting conventions of a horror story.
The analyses in science journalism such as Garrett's were neither false nor deliberately slanted. They were often epidemiologically useful, facilitating rapid identification of and response to public health threats. But the embellishments accrued, circulating (like microbes) until they became conventions. As fictional outbreak accounts dramatized the scenarios of disease emergence, they consolidated the conventions of the familiar story. In this chapter, I will chronicle the circulation of the language, images, and story lines through scientific and medical publications, journalism, fiction, and film to document how they became conventional and to introduce the narrative they produced in the process. That narrative links the idea of disease emergence to worldwide transformations; it interweaves ecological and socioeconomic analysis with a mythic tale of microbial battle over the fate of humanity. The outbreak narrative fuses the transformative force of myth with the authority of science. It animates the figures and maps the spaces of global modernity. It also accrues contradictions: the obsolescence and tenacity of borders, the attraction and threat of strangers, and especially the destructive and formative power of contagion. It both acknowledges and obscures the interactions and global formations that challenge national belonging in particular. By invoking Benedict Anderson's Imagined Communities in my chapter title, I mean to designate how the outbreak narrative articulates community on a national scale, as it depicts the health and well-being of those legally within the borders of the state as a mark of their belonging. The outbreak narrative is a powerful story of ecological danger and epidemiological belonging, and as it entangles analyses of disease emergence and changing social and political formations, it affects the experience of both.
DISEASES WITHOUT BORDERS AND THE OUTBREAK NARRATIVE
Microbial indifference to boundaries is a refrain in both scientific and popular writing about emerging infections. "Like science," Krause explains at the beginning of his foreword to Emerging Viruses, "emerging viruses know no country. There are no barriers to prevent their migration across international boundaries or around the 24 time zones." Emerging infections offer proof that the industrialized and technologized North cannot afford-economically, socially, politically, and medically-not to think about health globally. The 1992 report issued by the Institute of Medicine's Committee on Emerging Microbial Threats to Health begins with the observation that the HIV "disease pandemic surely should have taught us, in the context of infectious diseases, there is nowhere in the world from which we are remote and no one from whom we are disconnected." Preston dramatizes the point in The Hot Zone when a man suffering from an especially devastating hemorrhagic fever, Marburg, boards a plane. "A hot virus in the rain forest lives within a twenty-four-hour plane flight from every city on earth," Preston writes. "All of the earth's cities are connected by a web of airline routes. The web is a network. Once a virus hits the net, it can shoot anywhere in a day-Paris, Tokyo, NY, LA, wherever planes fly."
Like Garrett, Preston follows much of the scientific literature on the topic when, despite evidence to the contrary, he depicts this "microbial traffic" as one-way: from the primordial rainforests of the impoverished developing world to the metropolitan centers of commerce and capital. This convention is part of the vocabulary and geography of disease emergence. An infection may be endemic to an impoverished area, but it emerges when it appears-or threatens to appear-in a metropolitan center of the North. That is why microbes can be simultaneously "primordial" and "emerging."
Although scientists and science writers widely credit HIV with the renewed attention (in the North) to the global threat of infectious disease, hemorrhagic fevers, such as Ebola, Lassa, and Marburg, typically dominate these accounts. Like HIV, they cause gruesome illnesses and death, but they are more infectious and have significantly shorter incubation periods and duration. Victims generally fall ill within two weeks of infection (usually more quickly), and the progression of the outbreak is easy to track. While the HIV/AIDS epidemic had spread beyond containment by the time of the 1989 conference, teams of epidemiologists and researchers from such agencies as the Centers for Disease Control and Prevention (CDC), the WHO, and the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) had been able to stem the recent outbreaks of hemorrhagic fevers that did not burn out on their own. To those who had witnessed the effects of these fevers, however, the nightmare scenario would be a fusion of the two: a virus with the traits of the hemorrhagic fevers and the scope of HIV.
Excerpted from Contagious by Priscilla Wald Copyright © 2008 by Duke University Press. Excerpted by permission.
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Table of Contents
1 Imagined Immunities: The Epidemiology of Belonging....................29
2 The Healthy Carrier: "Typhoid Mary" and Social Being....................68
3 Communicable Americanism: Social Contagion and Urban Spaces....................114
4 Viral Cultures: Microbes and Politics in the Cold War....................157
5 "The Columbus of aids": The Invention of "Patient Zero"....................213