AIDS and the Destiny of Gay Men
Why did AIDS happen to gay men?
The answer may seem so obvious that it barely merits asking, yet different people have different "obvious" answers. To some, particularly in the gay community, the gay/AIDS epidemic is often considered a result of social and governmental homophobia and neglect, even an act of genocide. To others, particularly conservatives, it's considered the fault of gay male promiscuity, even the inherent unhealthiness of gay sex. To still others, particularly those who take public health warnings to heart, AIDS was simply an accident that just happened to sideswipe gay men first on its way to careening through the entire population. Each person's "obvious" answer tends to reveal that person's views on a host of subjects, many of them unrelated to AIDS itself.
It therefore might surprise many people to know that researchers who study the epidemic are almost unanimous in their understanding of why AIDS spread so disastrously among gay men, and their explanations have little to do with those mentioned above. AIDS, they say, is like all epidemics: an ecological disturbance that resulted when human behaviors created a niche for a particular microbe. To understand how the HIV epidemic occurred in a given population, we have to study how that population's behavior patterns changed in ways that provided HIV with its ecological opportunity.
The first portion of this book explores that topic. As a result, it is not about how homophobia contributed to the epidemic, or about what the government or the media did or did not do to exacerbate it. It is not about the failings of the medical establishment, or the ego of scientists, or the greed of drug companies. There have already been a number of excellent books on those subjects, and there will undoubtedly be many more in the years to come. Instead, what I seek to explore here is how gay behavior itself interacted with HIV to contribute to the epidemic. I will try to look at AIDS as an ecological rather than as a political or social event, and attempt to shed light on the process of the epidemic from what you might call the virus's point of view. To do so, I will try to place the epidemic firmly in the context of the previous sexually transmitted epidemics that struck gay men in the seventies, thereby questioning the "AIDS exceptionalism" that would have this epidemic stand as a unique and unfathomable event. I will examine theories of why, despite widespread knowledge about safer sex, the epidemic has continued to rage almost unabated among gay men. And I will attempt to explore why many experts believe that if AIDS is ever partially or completely cured and gay men return to the behavior patterns of the past, the same kind of disaster will almost certainly happen again.
I am a gay man. I live in New York City, Ground Zero of the epidemic, one of the urban environments most devastated by AIDS. I arrived here almost a full decade before the epidemic began, and was an enthusiastic participant in the gay sexual culture I will shortly describe. I believed then, as I believe now, that homosexuals have been terribly oppressed by both the wider society and by our own legacy of self hatred, and that gay liberation offers genuine hope of changing our lives for the better. Throughout the seventies I came to believe that gay people were making genuine progress toward building a future where others would not have to suffer as we had.
Then I watched with horror as a plague descended and much of my world sickened and died. It is almost impossible to overestimate the impact of the AIDS epidemic on gay men, to exaggerate what happened when a group of people deeply stigmatized for the way they make love finally emerged from the shadows, proclaimed that Gay Is Good, and then were struck down by a disease spread through the very behavior that was the focus of their stigma. The overwhelming shock of this was something many gay men could scarcely deal with, but then we scarcely had time. We had work to do. We had to discover and fix whatever was causing the epidemic, a task we thought was quickly accomplished with the invention of safer sex. We had to aid the stricken, which we did with the creation of a vast network of personal and institutional caregiving and volunteerism. And we had to fight for a cure, which we did with everything from inside-the-Beltway lobbying to tenacious street activism.
I participated in all of these efforts. I practiced and promoted safer sex. I volunteered and cared for friends and bore witness to their suffering and their deaths. I wielded the tools of activism and advocacy journalism to fight a desperate, and in many ways successful, guerrilla war against the pernicious agenda of blame. I worked for a cure, a struggle now bearing fruit in new drugs that are now prolonging the lives of people with HIV. I believed, as most of my activist colleagues believed, that AIDS was an accident, that we were its heroes as well as its innocent victims (as, in many ways, we were and are), and that if there was any grain of truth to the idea that gay male behavior had played some role in AIDS, there was no point dwelling on it, since that would play dangerously into the hands of our enemies and since the problem had been solved by safer sex. In all these respects, I not only followed the party line, I helped write it.
But as the years have passed I have also followed the epidemic with a growing sense of foreboding. AIDS is not living up to our activist expectations. Despite the fact that by now virtually everyone knows how AIDS is spread and how to avoid it, it is continuing to saturate the gay male population at the same levels it always has. It is also continuing to devastate IV drug users who share needles, and their sexual partners and, often, their children. But - and this is a very major but - it is not producing a self-sustaining heterosexual epidemic in the middle class, mainstream American population. True, there are growing cases of what is sometimes called "heterosexual AIDS," but virtually all of these cases occur when HIV is passed from IV drug users to their sexual partners and children. While this is a tragedy for those concerned, and an additional blight on the poorest in America, it is a very different thing from a self-sustaining heterosexual epidemic which would, by definition, be fueled by heterosexual transmission alone. Twenty years into the AIDS epidemic among gays, the absence of such a self-sustaining heterosexual epidemic can no longer be explained by the fact that it hasn't had time to occur. It is not happening because, as we will see, the sexual ecology of middle class western heterosexuals does not promote the efficient spread of HIV, and it will not occur unless there are major changes either in the biology of HIV or the behavior of heterosexuals or both. So something is happening on one side of the AIDS equation, among gay men and IV drug users, that is not happening on the other side, among the surrounding middle class majority. Something potentially disastrous to both the prospects of the inner city poor and the gay male community. And for me, by extension, something with enormously troubling implications for the future of gay liberation.
In my case, then, Rene Dubos' famous ecological injunction to "think globally, act locally" has convinced me to search more deeply for the roots of AIDS where I find them, here in my own environment. The word ecology comes from the Greek words for "home," oikos, and "knowledge," logia, and is sometimes translated as "home wisdom." This book is my attempt, as an AIDS activist and a gay journalist, to seek a home wisdom in the age of AIDS by taking an unblinking, and admittedly painful, look at the means by which an invader was able to roll like a Trojan Horse into the center of our lives.
An ancient adage is "Know your enemy." For most people in the age of AIDS, we have thought of the enemy as HIV itself. We have generally failed to recognize that an equal if not greater enemy is the complex set of conditions that favor HIV's transmission. Without those conditions, HIV would stand outside of our bodies and our lives like a million other potentially deadly viruses that swirl about the earth and would kill us if they could, but cannot because they cannot infect us. So while it is unquestionably important to know everything we can about the biology of HIV, it is equally crucial that we learn everything we can about the ecology, the process, the condition, that allows this particular virus entree into our lives. Only by knowing that enemy can we fight it.
When it comes to epidemiology, our ignorance stands in stark contrast to our often intensive study of other aspects of AIDS. Gay men have become reluctant experts at virology and immunology. We study the fluctuations of pharmaceutical stocks, are conversant with the ins and outs of the federal health bureaucracy, and often know more than our own doctors about the resourceful mutations of a tiny retrovirus whose very existence was unknown to the most advanced biologists less than a generation ago. But we have generally failed to recognize that the epidemic is itself an organism, a macroparasite that operates by laws as elegant as Einstein's and as discernible as Mendel's. Although it is now possible to understand the larger ways of the epidemic as surely as we understand the predations of HIV on the cellular level, we gay men, as citizens and victims, have generally chosen not to. And that is no accident.
HIV truly strikes us where we live. Its means of transmission - sex - is the very thing that to many of us defines us as gay men, drives our politics and our erotics, gives us our modern identity, provides the mortar of much of our philosophy and community, animates much of our lives. For these reason we have good cause to shy away from a close examination of how certain key elements of our identity contributed to the disaster that now engulfs us. We have another good cause as well: Gay men have been blamed for AIDS since the disease appeared in mid 1981, and our reflexive response has been to resist being made scapegoats for a scourge that counted us among its primary victims. It has seemed politically wise instead to shift the focus to the substantial failings of government and media and the scientific establishment. Those failings were so egregious, and contributed so seriously to the epidemic in the early years, that it was hardly a stretch of the imagination to believe that AIDS was the result of factors wholly outside the gay world.
Someone has remarked that if you want to tell a really convincing lie, you have to believe it yourself. If so, AIDS activists must sound very convincing when we argue that "Sex does not cause AIDS, a virus does." Or when we say, "There are no risk groups, only risky behaviors." Or when we insist, "It's not who you have sex with or where you have it that counts, it's what you do." Fighting the soundbites of blame with our own soundbites of self defense has seemed essential to the goal of convincing ourselves of the absolute justice of our cause. And once gay men came to believe in the mid eighties that we had largely solved the problem of HIV transmission through the invention of safer sex - an invention, by the way, that society at large did little to encourage and much to hinder - further discussion of our own role seemed not only politically unwise, but pointless, self loathing, downright mean. And so we have thrown up a fog of half truths, and in the process we have blinded ourselves.
Such was already the situation in 1987 when Randy Shilts published And the Band Played On. In that seminal work he described the epidemic as a result of a series of failures by the government, the health and research establishments, the media and, importantly, the gay community. Yet he was vilified by many gay and AIDS activists who felt that any discussion of gay men's role was too much discussion. Many felt then, and many still feel with some justification, that it is better to circle the wagons, fight off the hate mongers and leave any theoretical discussions of our own possible role in AIDS to the ponderings of future generations.
Those who disliked Shilts' book for those reasons may absolutely hate this one. For here I have deliberately omitted almost all mention of the role of government, the research establishment and the media in the genesis of the gay AIDS epidemic, and have focused almost exclusively on the ways that gay men ourselves - inadvertently and innocently but nonetheless decisively - facilitated the epidemic. I have done so not because the failures of government and media and science were not important. They were very important. But there are several pressing reasons why our own behavioral role must to be explored and understood, especially now, as new drug therapies open up the possibility of a paradigm shift in the epidemic.
For one thing, it has become increasingly clear that our failure to delve into sexual ecology is itself contributing to the epidemic's longevity. Strategies for dealing with the so-called Second Wave are hobbled by a distorted, incomplete and thoroughly unecological view of the processes of epidemics generally, and this one in particular. In the most literal sense, our self-enforced ignorance about sexual ecology is killing us.
Some might argue that while this may have been true in the past, new advances in drug therapy are rendering traditional approaches to prevention moot and even promising to end the epidemic. Why stir things up now? But if anything, sexual ecology is more important now than ever before, precisely because now, for the first time since the epidemic began, there is both genuine hope of ending it and a genuine danger of derailing that opportunity forever. The next several years will be particularly decisive for the future of AIDS. Newly developed anti-viral drugs are becoming available, and newer and better formulations are promised. But these drugs do not immediately or completely eliminate the virus from the body. Instead, they suppress viral replication, placing HIV under intensive evolutionary pressure. We fondly hope that this pressure will be too much for HIV and that it will succumb. But HIV is without question the most mutable virus yet encountered, and there remains a very real danger that it will somehow manage to elude even the most potent drug combinations and emerge in drug-resistant forms. If it does, that would obviously be tragic for the unlucky individuals in whom it occurs. But if gay men mistakenly believe that the epidemic is waning and return to the habits of the past, rapidly transmitting new, drug-resistant strains of HIV across newly reconstituted viral highways, the potential for tragedy is almost unthinkable. It is altogether possible that over the next several years gay men's failure to comprehend and modify our sexual ecology could lead to a decisive Third Wave of the epidemic, this time with drug-resistant strains of HIV that can never be treated by the very drugs otherwise most likely to work. So failure to understand sexual ecology could result in the squandering of our last best hope of ending the epidemic.
HIV aside, there are powerful additional reasons why we need to face the facts of why AIDS happened to gay men. Almost every researcher studying the epidemic is convinced of one overarching fact: that if gay men ever recreate the sexual conditions of the seventies, the same kind of thing will happen again with other microbes. There are already drug-resistant or incurable diseases circulating in the gay population - things like hepatitis C, antibiotic-resistant gonorrhea, various strains of herpes - and they all stand poised to sweep through gay culture the moment we provide them an opportunity to spread. There are still others that, as of this writing, are only dimly understood, such as the viral cause of Kaposi's sarcoma. And, say the experts, there are probably many more microbes whose existence we know nothing about, just as we once knew nothing about HIV. If gay men recreate the right conditions, such pathogens would almost certainly thrive and spread. So a key challenge facing us in a post-AIDS world, if there is one, is to prevent old diseases from mutating and spreading, and entirely new ones from sprouting from the same fertile soil that germinated AIDS.
Finally, an understanding of how AIDS happened to gay men transcends AIDS itself. We live in a world of rapidly emerging diseases where our faith in the power of drugs to tame infectious illness has been humbled by the wiliness of microbes, their ability to evolve into drug-resistant strains, and the brilliantly adaptive way they exploit the niches we provide them. The story of gay men and AIDS is a telling parable of modern life, an example of how a mistaken belief in the powers of medicine contributed to a lifestyle of intrinsic risk. To understand that story is important for all people, because it challenges the pervasive myth that humans have somehow transcended the limits of the biological world. The extinction gay men have faced is a prologue to what may ultimately face everyone on the planet if we do not learn the lessons all around us.
Our reluctance to examine the epidemiology of AIDS has helped perpetuate a number of myths about the epidemic, at least within the gay world, and so the first chapters of this book will attempt to walk the reader through AIDS as it is now understood by researchers, challenging the misconceptions that have become ingrained in the public imagination of the disease.
Myth: The epidemic occurred primarily because HIV is a new disease in humans, one that crossed from simians to people very recently and found a hospitable niche. In fact, while HIV clearly evolved from a simian virus, it appears to have existed in humans for at least several decades before the epidemic began in the late seventies. It may even have occurred, though rarely, for centuries. It now seems likely that the primary reason the epidemic began when it did was not because a microbe jumped from animals to people, but because large scale changes in human behavior provided HIV with radically new opportunities to spread.
Myth: It was essentially an accident that the epidemic struck gay men. In fact HIV is extremely selective and only produces epidemics when a population's behavior provides it with a niche. Without favorable conditions, HIV cannot spread in a given population. Among gay men in the seventies, our sexual behavior was extraordinarily conducive to the transmission of HIV.
Myth: These kinds of behavioral explanations cannot really explain why AIDS hit gay men when it did, because gay men have always behaved essentially the same. In fact, gay history provides compelling evidence that there were very significant changes in gay male behavior in the years preceding the epidemic, the very kinds of changes needed to facilitate the rapid spread of HIV. These included a sharp increase in anal sex with multiple partners, the appearance of so-called "core groups" of men who engaged in extraordinary levels of risky sexual behavior, and a rapid increase in the amount of sexual mixing between people in those core groups and the rest of the gay population. Indeed, few groups in history changed their overall sexual behavior as rapidly and profoundly as homosexual men in the decades before AIDS.
Myth: It is homophobic to implicate aspects of gay behavior in the epidemic because straight people behave essentially the same. In fact, HIV will soon sweep the heterosexual population in the U.S. the same way it swept through gay men. In fact, twenty years after HIV began its relentless decimation of the gay population, it remains largely confined to the same heterosexual groups it infected from the start: hemophiliacs, intravenous drug users, and their female sexual partners and children. The only self sustaining heterosexual epidemic in the U.S. appears to be among crack cocaine addicts, who share many factors of sexual ecology with gay men.
Myth: While the above might be true here in the developed world, HIV is a heterosexual disease in the rest of the world, proving that gay behavior is irrelevant. In fact, HIV is spreading in an extremely selective way in the wider world, causing disastrous epidemics in places where heterosexual ecology favors its spread, and causing no epidemic at all in places where heterosexual behavior is less conducive. If anything, the highly selective spread of HIV around the world shows that AIDS is neither a gay nor a straight epidemic, but an ecological epidemic that exploits certain behaviors, chief among them the practice of having large numbers of partners, straight or gay.
Myth: Multiple partners don't matter, because gay men's promotion of condoms created a workable version of safe sex that allows people to continue to have multiple partners safely. In fact, the condom code does not seem ever to have been very successful in containing the epidemic. The drop in new infections in the mid eighties, for example, probably occurred because most of the susceptible gay men were already infected. Now that a new generation of susceptible young men have entered the gay world, they are getting infected at rates that indicate that about half will eventually get AIDS, which is about the same ratio as in the older generation. The fact is that most people do not seem able to use condoms consistently enough to stem the epidemic.
Condoms are very important in the battle against AIDS, but total reliance on the condom code blinds us to the fact that condoms are just one narrow possibility in the possible arsenal of responses to AIDS. The condom code in the gay world is, in many ways, as much a political as a medical construction. Its dual purpose has been to prevent HIV transmission while preserving the "sex-positivity" of gay male culture, thereby proving that the gay sexual revolution of the seventies can continue during a fatal epidemic of a sexually transmitted disease. But it provides virtually no room for error, and is in many respects anti-ecological, a classic "technological fix," because it has never addressed the larger factors in the gay environment that helped spread HIV. Since it is not working to contain the epidemic, we need to explore more holistic possibilities, which involve challenging and changing larger factors of gay life that encourage unsafe behavior.
Finally, the most potentially dangerous myth of all.
Myth: If AIDS is cured or contained by drug treatments, gay men can return to the sexual lifestyle of the seventies. Ultimately, to understand sexual ecology is to understand that the gay sexual revolution of the seventies was profoundly anti-ecological. Gay men can never go back.
In the final portion of this volume I will discuss how ecological thinking might help gay men create a new gay culture that could lower overall risk. The goal is a "sustainable" gay culture that both affirms gay identity and sexuality and, at the same time, provides a built-in measure of safety that would prevent the resurgence of AIDS or the emergence of new epidemics. I will draw parallels between the challenge facing gay men and that of other ecological movements, particularly the quest for population control, which shares many areas of common concern with AIDS prevention. But before we delve more into these issues in more detail, it's important to first draw connections between the basic concepts of ecology, disease transmission and sexual behavior that will appear again and again throughout this book.
A PRIMER ON ECOLOGY
Most people associate ecology with efforts to preserve nature, to recycle waste products and conserve resources, and heal or prevent the wounds people inflict upon the world's ecosystems. But although these are important results of ecological thinking, ecology itself is much more. In its original sense, it is the science of connections. It seeks to describe the vast web of interrelationships that tie living things to their environments, its fundamental premise being that a change in any part of one of the "tangled banks" of life we call ecosystems can have broad and often unexpected implications for any living thing seeking to survive within them.
In some ways ecology is not a science so much as a way of looking at life itself. Its perspective begins with the tiniest systems that constitute life - atoms, molecules, energy - and radiates out in widening circles of complexity until it arrives at its basic units of study, which are "populations." How does a given population survive and evolve? How does it interact with other populations? How does it adapt to the challenges before it? To answer these questions ecology widens its scope to consider the "ecosystems" in which populations live, an ecosystem being the combination of a population and its environment, functioning together as a unit.
Charles Darwin is often called the first great ecologist. His seminal observation that evolution proceeds through natural selection provided the essential underpinning upon which all of modern ecology is based. Natural selection is the chief animator of ecology, and the primary engine of natural selection is adaptation, the process by which a population changes and adjusts to meet its constant challenges. In one of the most significant of all biological insights, Darwin realized that genetic adaptation, or evolution, occurs for two basic reasons. Organisms are always struggling against each other for survival, and random mutations sometimes occur that give an individual organism an edge in survival. Whenever such a mutation occurs, its possessor has an increased ability to reproduce and pass the mutation along. If the mutation continues to provide an edge in survival and reproduction, it may eventually predominate in the species, or help create a new species altogether.
Humans share genetic evolution with other organisms, but we possess an ecological trait unique to us: cultural adaptation. This is the process by which people consciously develop modes of living to meet the challenges of their environments, and then pass them down to succeeding generations through culture and education. From an ecological perspective, human cultures are far more than just "lifestyles" comprised of rituals and rules with symbolic meanings for their members. Cultures are adaptive strategies for survival, ways of life that allow their members to cope with the complex obstacles that nature, and other people, places in their way.
Modern ecology has produced sub disciplines called "human ecology" and "medical ecology" that view human health the way ecologists in general view the processes of life - as part of the interconnectedness of everything with everything else. To medical ecologists, human disease is more than just the tiny workings of microscopic or toxic invaders on the body, although it certainly includes that. Human disease, and the more difficult to measure entity called human health, are reflections of the complex relationships between human populations and their habitats, which include neighboring human populations, other populations of animals and plants and microscopic fellow travelers, and the inanimate world of elements and energy and earth.
The health of a given human population is a measure of adaptation: how well that population has adapted to its constantly changing habitat. Populations in good heath are considered to be successfully adapted to the world they find themselves in. Those in precarious health have not found, or have somehow lost, the most advantageous accommodation with their habitats. And populations afflicted with chronic illness, or in the grip of plagues, have for the moment failed to find a successful niche and are, in the lingo of environmentalism, committing "ecocide," self-destruction via ecological catastrophe. If such a failure goes unchecked, that population faces oblivion by the same relentless law that has led to the disappearance of over 99 percent of all of the species that have ever lived on earth: extinction via natural selection.
To medical ecologists, no infectious disease simply happens. If one of the great biological and medical triumphs of the nineteenth century was the discovery that infectious diseases are largely caused by specific microbes, an equally important insight of the twentieth century is that diseases are more than the simple sum of their microbial causes. Almost as soon as medicine discovered "germs," it was faced with a corollary question: why do some people, and some populations, succumb to some germs while others do not? Why is cholera typical of Bengal but not Brittany? Why does sleeping sickness affect Africans but not Austrians? Why does one person exposed to influenza become ill and another person not? If diseases are caused by germs, why do some germs affect some people and pass others by? From these questions the science of epidemiology was born, and the explanations it produces often complicate, if not undermine, the simple idea that germs cause disease. It seems that germs need help, and we humans are often the ones that provide it.
Take, for example, the story of schistosomiasis in modern Egypt. When epidemiologists look at this medical debacle that now afflicts up to 58 percent of the rural Egyptian population, they do not simply see a nasty, debilitating parasitic disease spread by waterborne snails. They see that, of course, because that's what schistosomiasis is. But beyond that they see a wider web of ecological - and therefore in a sense preventable - causes and effects.
The immediate cause of schistosomiasis is a parasite called a schistosome whose intermediate hosts are snails that thrive in slow moving streams and stagnant ponds. Each infected snail can produce thousands of male and female sporocysts that are released from the snail and swim out into the water, free to infect any humans they come into contact with. Once these sporocysts infect their unfortunate human hosts, they migrate to the heart, lungs and liver, where they mate and reproduce, causing debilitation, weakness, weight loss, lassitude and decreased resistance to other diseases.
For thousands of years the snails that serve this terrible intermediate function were kept in check by two notable factors of Egyptian ecology. One, the snails do not thrive in fast moving streams or rivers, and the Nile flows swiftly; and two, Egypt was irrigated each year by the flooding Nile, which deposited silt and water (and snails) on the land and then soaked in, giving nourishment to the soil but leaving any stranded snails to die in the disappearing puddles and ponds. So there was schistosomaisis throughout the ages in Egypt - we see its biological record in the tissue of mummies and its cultural record in the carvings of the hieroglyphs - but apparently not very much. Indeed, it's doubtful that Egypt could have sustained such millennial glory if a majority of its people had been stricken with such a debilitating disease.
Then, in the mid twentieth century came the momentous decision to build the Aswan High Dam, the greatest engineering project in North Africa since the pyramids. The Aswan Dam ended the annual rhythm of the Nile's floods and replaced it with thousands of miles of stagnant irrigation ditches, canals and holding ponds covering the length and breadth of the country, waterworks that remain submerged for much of the year. These were ideal habitats for the snails, and their population exploded. As went the snails, so went the prevalence of schistosomes. And since rural Egyptians routinely wade in these irrigation works as part of their daily work, so went the prevalence of schistosomiasis in Egyptians. Suddenly, almost overnight, this disease came to infect a majority of the population, a modern catastrophe from which there is, at present anyway, no way out.
From a narrow medical perspective, schistosomiasis is, and remains, a simple disease caused by a parasite long native to, and "natural" to, the Nile. In the lingo of AIDS activism, we might say "Irrigation doesn't cause schistosomiasis, a sporocyst does." But from a broader ecological perspective, the calamity of schistosomiasis in modern Egypt is part of a complex web in which sporocysts, agriculture, engineering, a desire to tame the annual floods of the Nile, economic development, overpopulation, the politics of the Cold War, techniques of irrigation farming and numerous other factors combined to create a human disaster.
ALL DISEASES ARE ECOLOGICAL
When looked at in this way, every infectious ailment is both narrowly biological and broadly ecological. The difference between the health of the people of Katmandu, who typically suffer from chronic intestinal parasites caused by drinking water contaminated with fecal matter, and the health of their counterparts in Paris, where such diseases are virtually unknown, is an example. Katmandu has no modern sewage system and no uncontaminated source of potable water, while Paris constructed such systems over centuries.
The two biggest killers of Americans - heart disease and cancer - are both deeply embedded in behavior and environment. Heart disease is primarily caused by the lifestyle of too little exercise, too much obesity, too much salt and fat in the diet, and smoking. Many of the contributing factors that affect the development of cancer are related to our ingestion of carcinogenic pollutants unknown to our ancestors.
Across the planet and throughout our lives, the diseases that buffet us, from the most trivial to the most fatal, all have environmental components. Think of the toddler afflicted with a continuous stream of minor colds that circulate in the sneezy environment of the day care center. The sub-Saharan nomad, weakened by a famine caused by overgrazing and desertification, succumbing to a simple infection she might otherwise have survived. The non smoking bartender dying of lung cancer from a lifetime of breathing other people's smoke. The person felled by e coli poisoning after eating a tainted hamburger. The former resident of Love Canal dying of cancer caused by toxic wastes leaching from the backyard. In the broad purview of medical ecology nothing in our varied biosphere just happens, especially not disease. The microbial world, the chemical world, the realm of toxins and pollutants, parasites and microbes, are intimately connected to our behavior, our physical condition, our diet, all of which are intimately connected to the economic world, the cultural world, the social and religious and technological world around us. All ebb and flow in a seamless web of cause and effect. It remains for us to seek, so far as we are able, to understand these processes. Or, if we cannot or will not, to suffer the consequences.
SEXUALLY TRANSMITTED DISEASES
Most human diseases are infectious or contagious; that is, they are caused by microscopic entities passed to their human hosts from previously infected persons, insects, animals or plants. Whether through air, water or food, a rabid dog or a hungry tick, a sneeze or a kiss or a curse, living beings transmit diseases amongst ourselves in endless chains of cause and effect.
One specific group of infectious diseases are those transmitted by the physical act of love. Sexually transmitted diseases (STDs) differ from other infectious diseases in that their transmission generally requires the exchange of bodily fluids - semen, pre-ejaculatory fluid, cervical/vaginal fluids, saliva, mucus, blood, feces - during sex. No one knows precisely when sexually transmitted diseases first appeared in human populations. There are early records contained in Hippocratic treatises from the fifth century B.C. that refer directly to genital herpes and indirectly to lymphogranuloma venereum, and other ancient texts, including the Bible, mention STDs. Certainly since human societies grew advanced enough to sustain urban populations in the thousands and tens of thousands, people have been afflicted to varying degrees with serious diseases spread through sex. The more common are syphilis, gonorrhea, genital herpes, genital warts and chlamydia, but the list also includes hepatitis A, B and C, cytomegalovirus, Epstein-Barr virus mononucleosis, nongonococal urethritis for men, pelvic inflammatory disease for women, and several others, undoubtedly including some not yet recognized. (Researchers now believe, for example, that a previously unknown sexually transmitted herpes virus is responsible for Kaposi's sarcoma. This undoubtedly would not have been noticed were it not for its close association with the AIDS epidemic.)
At certain times, among certain populations, STDs were rare or unknown. At other times they were more common but still largely limited to certain core groups within the population - prostitutes and those who patronized them, soldiers, prisoners, the young, the very poor and so on. At still other times they were pervasive dangers that were considered background threats to the health of almost anyone. And at still other times they burst into epidemics, plunging whole societies into medical, cultural, economic and religious crisis and altering the course of history. Some historians now argue, for example, that the vast syphilis epidemic that swept Europe from the 1490s onward may have contributed to the Reformation and the rise of Puritanism, a development that still has echoes in our own time. There are, it bears repeating, no accidents in nature. If differing rates of diseases among populations are largely the result of different human ecologies, differing rates of sexually transmitted diseases are largely the result of different sexual ecologies.
Sexual ecology, then, consists of the entire spectrum of causes and effects that influence the spread of sexually transmitted diseases. It includes the direct microbial cause of an STD, the way it enters the body and the ways it reproduces and interferes with the normal working of cells, thereby causing disease. It includes the role specific sexual behaviors play in transmitting microbes from one person to another. It includes any biological cofactors that determine whether, once exposed, infection takes place, and once infected, illness results. And it includes the ways in which the course of illness itself impairs or enhances a person's ability to pass the infection on to others.
Sexual ecology also includes the ways in which human behaviors affect disease transmission, including the mysteries of why individuals and entire societies behave in ways that place them a sharply different risks for certain STDs. Beyond beliefs and ideologies and group behaviors, it includes the ways that human technologies impact on STD transmission. How do diseases travel from one part of the world to another: slowly on horseback, more swiftly on steam ship, instantly on jumbo jets? How does the availability of treatments, cures or vaccines, or the lack of them, affect transmission, or the mutation of old diseases into new strains? How do the cultural values that stem from access to certain technologies or medicines affect our beliefs about disease, thereby affecting our behavior?
It is high time to apply the fundamental questions of ecology to the terrible event of AIDS in the gay world, to ask the tough questions and to follow wherever they lead. How, for example, were the behaviors that favored HIV in the gay world created? How were our ecosystems altered in ways that facilitated HIV? What were those changes? And if the epidemic can be explained in terms of altered ecology, does that suggest ways it can be curbed or ended? Can the gay male community use the basic knowledge of medical ecology and human adaptation to readapt our sexual behavior, to undo the changes that have almost destroyed us? And can we do so in ways that preserve the vital human gains of gay liberation? Just as environmentalists ponder the creation of "sustainable" economic growth that doesn't destroy the planet, or "sustainable" cities that don't pollute, can we create a sustainable gay culture, one in which people are free to be homosexual, but one that does not destroy the very souls it liberates?
Some may object to this discussion, fearing that it will damage the reputation of gay men. But here is the quandary: Containing the epidemic requires a full, open understanding of its mechanisms. Precisely such an understanding, especially an open public discussion of it, seems to play into the hands of anti-gay forces. In a cruel irony, the only public discussion likely to save gay men from further saturation with AIDS is the very public discussion we least want to have, one almost guaranteed to embarrass many of us.
But I believe that there is little that a Jesse Helms or a Pat Robertson can do to gay men that approaches the damage wrought by the endless continuation of AIDS. The application of ecology to AIDS has importance not only for the lives that stand to be saved, but for the social and political movement that stands to be rescued. AIDS and the series of epidemics that preceded it in the seventies have cast a pall over the entire edifice of gay liberation. The appearance of a multitude of epidemic disasters almost immediately after gay men had carved out zones of sexual freedom has opened up the grim, almost unthinkable possibility that for gay men, sexual freedom leads inexorably to disease. As time goes on and the epidemic continues to rage among gay men while largely sparing the rest of the population, that nightmare grows only more plausible. It was one thing to believe we were accidental victims who would soon be joined in our sorrow by everyone else. It is quite another to discover that we will not be joined, that we stand almost alone, consumed with disease. Ultimately the only way to refute this nightmarish connection is to prove it wrong, and the only way to do that is by creating a sustainable gay sexuality in which gay men are both sexual and healthy. Free to love, and free from plague.
The first step in imagining that sustainable future is to go back in time and seek answers to how we got to this terrible impasse in the first place. Where did HIV come from? How did it enter our world? And are there clues in the story of the birth of AIDS that can help us bring about its end?
copyright © Gabriel Rotello, 1997
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