“He dreamt that the whole world was condemned to a terrible new strange plague that had come to Europe from the depths of Asia.” —Fyodor Dostoevsky, Crime and Punishment
The dream is terrifying, and the story is always the same. A wave of gruesome, unexplained deaths appears in some poor country. An infected person makes a sudden movement and crosses the tripwire of global epidemic. Panic and fear spread, outrunning the disease itself, until another catastrophe is somehow averted.This narrative, a familiar one by now, has framed reports of every infectious disease outbreak since the mid-1990s, from Ebola to plague to West Nile virus to this year’s SARS epidemic. Although unrelated to each other, these diseases are all described in the same way, using a common language and inescapable set of metaphors.
That process continues the one identified in Susan Sontag’s Illness as Metaphor (1978), a book-length essay that changed the way people think and write about cancer. Weighting the disease with meaning only isolated the people who suffer from it, she wrote; writing about it as a battle turned dying into defeat.With AIDS and Its Metaphors (1989), Sontag renewed her call for language to rid itself of military metaphor (why should a body be anyone’s battlefield?) and the dangerously Biblical language of plague (if it’s a punishment, what’s the crime?). Although obituary writers and eulogists may never stop singing hymns to “heroic battles” with illness, the language surrounding both of these diseases has, thankfully, more or less caught up to the science.
But as medicine makes one disease less terrifying, Sontag suggested, another one takes its place as the vehicle for the plague metaphor. “AIDS has banalized cancer,” she wrote. Over the past decade, emerging infectious diseases have done the same to AIDS, and this new plague narrative gives shape to outbreaks of “emerging” diseases like Ebola, West Nile virus and SARS; old ones that have “re-emerged” like cholera, anthrax and plague itself; and at least one, smallpox, that hasn’t killed anyone in twenty years. In this narrative, military metaphors aren’t metaphors at all; they are literal exhortations to send in the troops and stop the germs at the border.And the normative language of plague is stronger than ever. Only, in this case, the afflicted sinners aren’t just the sick ones—they are all of us living in an interconnected world, vulnerable to attack thanks to the folly of jet travel and third-world immigration.
This is what it has come to: Perfectly healthy people read articles about SARS and become afraid to visit stores a few blocks from their homes, because the people who shop there look like the ones wearing face masks on the other side of the world. Maybe the problem isn’t the science. Maybe it’s the writing.
In the mid-1980s, a group of American scientists began to suspect that AIDS might be just the first of many new infectious diseases.They met formally in May 1989, discussing similarities among diseases that were once considered unrelated, from Ebola to influenza to an Australian rabbit virus. In 1992, the National Institutes of Medicine published “Emerging Infections: Microbial Threats to Health in the United States.” The report named six factors responsible for disease emergence and warned that the world stood on the brink of a global epidemic. It also corralled a host of illnesses under the new rubric of “emerging infectious diseases.”
This new threat entered the popular consciousness in 1994, with the publication of The Hot Zone by Richard Preston and The Coming Plague by Laurie Garrett, two bestsellers that lay the groundwork for subsequent books and reporting about emerging disease. The Hot Zone, an account of a small Ebola outbreak imported to Reston, Virginia, and then quickly contained, generates its dramatic tension with the notion that the outbreak could have become a national catastrophe— the suspense of narrowly averted doom. The Coming Plague is more tragedy than thriller. The heroes of this book are the “disease cowboys,” maverick scientists who defy clueless bureaucrats and save the day with their quick wits and high technology; their nemesis is the hapless public health official unprepared to deal with AIDS, hemorrhagic fevers, Toxic Shock Syndrome and Legionnaire’s disease. Written just as AIDS appeared to be receding in the United States, these books re-introduce two important elements of the AIDS metaphor: unlimited risk and epidemic as punishment.
A scene from Outbreak, a film inspired by The Hot Zone, captures the first part of the metaphor on film. In-house experts explain to a horrified group of government officials the potential threat posed by a germ on the loose.They use a map of the United States, with known cases lit up in red. In three iterations, the map is engulfed in a red glow. It’s an arresting image, and one repeated with each new emerging disease to grab the headlines. But it ignores the fact that Ebola is not transmitted through close contact, and that victims become so ill so quickly that they rarely have an opportunity to infect people other than the ones caring for them.The image is nothing more than a version of the email chain letter I once received meant to illustrate the spread of HIV: receiving it symbolized exposure, sending it meant exposing someone else. The ominous tone of the message—that any contact with any other person put you at risk—completely ignores the factors that make one person more or less susceptible to the disease. It might be faulty logic, but the hyperbole once had a purpose.The radical assertion that everyone was equally at risk was used to counter the equally extreme argument that AIDS was a disease only of gay men or drug users, and therefore did not merit the concern of the larger population. Eventually, the human and financial cost of the epidemic tipped the scale toward caution.
The new plague narrative takes this caution to its logical extreme, shifting its focus from people who are actually sick (prior to the AIDS epidemic) or people who are potentially sick (HIV-infected carriers) to people who are potentially infected (everyone). The disease appears invincible, and its spread uncontainable. Despite the best efforts of scientists and public health officials to quickly determine the specific causes of an illness, how it is spread, and how it can be controlled, we are nevertheless advised to fear the hypothetical superpathogen: an airborne (influenza), rapidly mutating (tuberculosis) virus spread by asymptomatic carriers(AIDS) that causes sudden, gruesome death (cholera) and originates in an unreliable, politically unstable country (Ebola). SARS is just the most recent candidate to audition for the role of über-outbreak. In April, the London Observer explained that
For years doctors have feared the emergence of a “doomsday scenario”— a new, contagious, hard to- treat virus that would traverse the globe rapidly and kill millions, as Spanish flu did in 1918.“SARS gave the infectious diseases people a fright because they are always looking around for the next Black Death to appear,” said Dr. Joe Neary, chair of the clinical network at the Royal College of GPs. “But it doesn’t have the ingredients that would make a new global pandemic. It kills people, but very few. This isn’t it.” That does not, however, mean something far nastier is not lurking now in a remote corner of the planet.”
In the recent Secret Agents1, Madeline Drexler writes: “What many biologists fear most is a new deadly virus.‘If you wanted to think of an Andromeda strain, you would think of, say, a virus with a short incubation period that’s rapidly transmitted from person to person through aerosol, with potential for a high fatality rate and which could move very rapidly,’ says McDade, who in 1976 discovered the cause of Legionnaires’ disease. Influenza currently fits the bill—but so could something else, such as a hypothetically mutated Ebola virus that spreads through the air.”
In Killer Germs, identical twins Barry and David Zimmerman write,“Able to withstand cold winters, the tiger mosquito has already made its way at least as far north as Illinois. Global warming will only exacerbate the situation. Health officials feel it is only a matter of time before dengue, or some other arbovirus, emerges (or yellow fever re-appears from these aggressive vectors), and they are scared to death.”
Why give disease—in this case, disease caused by microbes that do not actually exist—more power than it has? Everything we know about infectious diseases tells us that each one has a specific path of transmission that offers clues about who is at risk and how it can be controlled. Malaria, for example, is caused by a parasite that lives only in the female of one particular species of mosquito. These Anopheles mosquitoes can carry the parasite from the blood of an infected carrier to another person. In places where the Anopheles mosquito is native, malaria is endemic, and people who live there have reason to fear it, but it can be controlled by draining stagnant water and fumigating. Similarly, plague is caused by the bacteria Yersinia pestis and carried only by one species of flea, Xenopsylla cheopis. It usually feeds only on rodents but may sometimes jump to other hosts given the opportunity. In places with existing pockets of plague-infected X.cheopis (including the western United States,Vietnam, Tanzania, and western India) contact with rat fleas is the most important factor determining risk for humans. In the United States, an average of thirteen people were infected by plague every year from 1970 to 1995. All but one of the cases were traced to a flea bite or contact with an infected animal.
So why, in these accounts, are the experts always “scared to death”? Perhaps because AIDS, and the failure of science and public health to stop it, showed that disease could once again assert itself as something beyond our power to control. It became more than just a catastrophic illness caused by the HIV virus, as if that weren’t enough. It became a reflection on society itself—a plague. The Coming Plague was the first and most forceful such exhortation: “AIDS is trying to teach us a lesson. The lesson is that a health problem in any part of the world can rapidly become a health threat to many or all.”
Inadequate surveillance by public health officials, irresponsible sex and drug use, unchecked immigration— all of these conditions have been represented, in various ways, as “causes” of the AIDS epidemic. Subsequent writers continue the quest for a moral to the story, hoping to identify the transgression that has invited the scourge of emerging disease. Arno Karlen’s Plague’s Progress suggests:“We have brought it on by rending the fabric of our environment, changing our behavior, and ironically, by our inventiveness in increasing the length and quality of our lives.” Occasionally, causality is so clouded in a muddle of speculation that it becomes completely nonsensical. From Killer Germs2: “Political turmoil is also causing mass migration of humans. In 1972, Idi Amin ordered all Asians out of his country, effective immediately.Tens of thousands of Indians and other Asians fled not only Uganda but the entire continent of Africa.Many people believe that the AIDS virus emerged from Uganda.”
Thus, only a period and a letter space separate Amin’s expulsion of Asian Indians from the AIDS epidemic in America. (This passage conveniently ignores a case—mentioned elsewhere in the same book—that dates AIDS as far back as 1959.) This collapsed causality informs the way the Zimmermans represent other diseases: “Then came AIDS… and Ebola and Lassa fever and Marburg and dengue fever and West Nile virus. They came, for the most part, from the steamy jungles of the world. Lush tropical rain forests are ablaze with deadly viruses. And changing lifestyles as well as changing environmental conditions are flushing them out. Air travel, deforestation, and global warming are forcing never-before-encountered viruses to suddenly cross the path of humanity. The result—emerging viruses.”
Once the specific causes of a disease are blurred, writers are then free to use metaphor to express illness in terms of its vague social causes. The effect recalls the early nineteenth-century belief, pre-dating the advent of germ theory, that infectious disease was caused by “bad air,” a miasma that somehow “bred” disease. Robert Kaplan, in The Ends of the Earth, speculates about the causes of the 1994 outbreak of plague in Surat, in western India3: “Another cause of the plague was the unusually hot summer of 1994 in the subcontinent, which killed animals, whose carcasses bred disease. The disease germs were spread by monsoons that had been intensified by hot summer air.” Y. pestis no longer causes plague; filth, heat and rain clouds do. Sontag argues that “something like what is supplied by miasma, the generalizing of infection into an atmosphere, is required to moralize a disease.” In the case of emerging infectious disease, the object of this moralizing is anything that brings the “modern” world of advanced, healthy, wealthy countries into contact with the “ancient” or “pre-modern” realm of the poor, sick Third World. Mess with the Amazon, and you risk unleashing its demons. Open your borders to immigration, and you expose your body to the germs that immigrants carry. In the new plague narrative, the distinction between ancient and modern is a constant theme. Nations are always either one or the other; outbreaks occur whenever a nation attempts to move from one to the other, or when a pre-modern person moves into the modern world. In 1994, The New York Times observed: “As India struggles to cope with a spreading outbreak of plague… it is doing so in ways that capture much of its character as a nation poised between the ancient and the modern.” Drexler writes: “More fresh fruits and vegetables come from abroad, where sanitary standards may not be as high as in the United States. And our meals are increasingly cooked by people untrained in the techniques of food preparation.”
The mobility of people across national boundaries, invariably condensed into the strangely archaic shorthand “jet travel,” is constantly singled out for blame. Again, this idea connects us back to a key piece of the AIDS puzzle: the totemic Patient Zero, a Canadian flight attendant who may have infected hundreds of his sexual partners in different cities with HIV. Although AIDS is not an airborne4 disease, that image of a virus crisscrossing the globe via 747 is one of the strongest metaphors to emerge in the new plague narrative. From the New York Times: “In this era of jet travel, planes fly faster than the time it takes for a newly exposed individual to become ill”; the 1994 plague outbreak in Surat was “a scary close call that underscored the fragility of our defenses in the age of jet travel.” From Foreign Affairs in 1996: “In the age of jet travel, however, a person incubating a disease such as Ebola can board a plane, travel 12,000 miles, pass unnoticed through customs and immigration, take a domestic carrier to a remote destination…infecting many other people before his condition is noticeable.”
With national health at risk every time a national boundary crossed, the military metaphor is indispensible. When used to represent cancer, it turns tumor cells into invaders, and the body into an army fighting against itself. In the AIDS narrative, the invader is external, a virus, but one that surreptiously undermines the body’s defenses— HIV is a guerrilla fighter. Resurrected again for emerging infectious disease, the military metaphor is stronger than ever. But the target isn’t an individual body; it is the nation. Public health and public safety are indistinguishable from each other; outbreaks of disease and bioterrorist attacks are perceived and defended against in precisely the same way, as in this passage from Killer Germs: “Any unusual occurrence, any behavior that appears suspect must be reported to local police immediately. Hospitals should be notified of any uncommon ailments. This perpetual state of alert and readiness, of ceaseless and untiring surveillance, is the price we are now compelled to pay for homeland security.”
It is instructive, here, that the authority we are urged to summon is not a doctor or epidemiologist but a policeman. The new plague narrative carries the military metaphor one step further, and one step closer to the average person, by turning sickness into a crime. Edward Marriott, in Plague5, speculates that “If diseases have personalities, plague is an escape artist, a criminal Houdini, tunneling from highest-security confinement to trigger new outbreaks, to wreak escalating havoc.” From the South China Morning Post, in an article on SARS: “The medical world moves cautiously when trying to pinpoint a killer.” In Drexler’s Secret Agents the central conceit is the pathogen as criminal: “Just as DNA fingerprinting has supplied crucial evidence to seal criminal convictions, it has revealed surprising connections in a teeming and, until quite recently, unsuspected microbial underworld.”
Because these “killers” use the bodies of the Third World traveler as their preferred means of transport, they too are implicated in the “crime.” An article in the London Observer raises suspicions about an early SARS case in China, a doctor in Foshan, Guangdong province. He came from “the heart of the Pearl River Delta, a once remote rural area of China now booming thanks to the overspill of nearby Hong Kong and a rash of sweatshops producing cheap plastic toys.”The doctor travelled to Hong Kong’s Metropole Hotel and died there, apparently infecting other guests. “Which makes the elderly doctor’s motives in boarding a bus, late in February, for Hong Kong a focus of speculation. Was he, as his family claimed, simply attending a wedding, or did he suspect he was harbouring something local medicine could not cure?”This passage neatly combines the two elements of the new plague narrative, turning the Patient Zero of the SARS outbreak, an errant traveler from “remote” Foshan, from unwitting vehicle into willing accomplice.
It would be tempting here to conclude that the underreporting of SARS cases in China and that country’s initial unwillingness to allow the involvement of international public health authorities in slowing the SARS epidemic are a direct consequence of the metaphors used to describe it—that the writing about an outbreak dictates its course. This is, of course, a dangerous simplification. Outbreaks are complicated. Access to health care and information bend their path; the policies that surround them are always limited by structures of power. But the new plague narrative has a force and momentum of its own. It has already proven capable of generating the effects of disease, even where the disease itself is absent. During the 1994 plague outbreak in Surat, cities in India that reported no cases were nevertheless shunned by the rest of the world, as were Chinatowns in cities with no reported SARS cases. In certain cases, the impact of the narrative is even more direct. Maclean’s reported on an incident at Toronto’s Grace Hospital on March 22, where one of that city’s SARS patients had died:
According to two nurses who requested anonymity, a Grace staff member responsible for infection control told a physician that day that he didn’t need to wear a mask. ‘It was bad for public relations,’ is how it was put, said one nurse. Added the other: ‘And it wasn’t just the infection-control people, it was management saying,‘You know, it’s not good PR to be wearing the mask, you really don’t need that mask, it’s overkill.
In other words, the hospital made medical decisions based on the public’s perception of the disease— one saturated by these metaphors— rather than the disease itself.
It is a development alarming enough to warrant another call to relinquish metaphor in writing about disease. The only useful metaphor, perhaps, is Dostoevsky’s. Dreams, after all, operate according to their own logic.They can show us what it is we truly fear, by rendering it in the image of something else.We know that they are dreams because those frightening images are more terrible and fantastic than anything we must ever face in waking life. There lies a dream’s beautiful paradox. It loses its power when we call it by name.