Epidemics of the Late Twentieth Century

In the West, epidemic infectious disease was regarded by the second half of the twentieth century as indicating an uncivilized state of mind, and was ascribed above all to nonwhite populations in parts of the world outside Europe and North America. This reflected structural inequalities in the world economy, as the great infections became increasingly concentrated in the poor countries of the Third World. By the middle of the twentieth century, however, rapidly increasing life expectancy was bringing rapid growth of noninfectious cardiac diseases, cancer, and other chronic conditions that posed new epidemic threats to an aging population in the affluent West. Under increasing pressure from the medical profession, the state responded not only with education initiatives but also with punitive measures directed toward habits, such as cigarette smoking, that were thought to make such conditions more likely. The arsenal of sanctions governments employed included punitive taxation on tobacco and the banning of smoking, under threat of fines and imprisonment, in a growing number of public places. Increasingly, institutions in the private sector also adopted these policies. They raised the question of how far state and nonstate institutions could go in forcing people to abandon pleasures that were demonstrably harmful to their own health. At the same time, they contrasted strongly with the reluctance of many states and companies to admit responsibility for cancer epidemics caused by factors such as nuclear weapons testing, the proximity of nuclear power stations to human populations, or the lack of proper precautions in dealing with radioactivity in industrial production.

In the 1980s, the identification of a new epidemic, known as acquired immune deficiency syndrome (AIDS), once more raised the ethical problems faced by state and society, and by the medical profession, in the past. Lack of medical knowledge of the syndrome and the danger of infection from contact with blood or other body fluids, posed the question of whether the medical profession had a duty to treat AIDS sufferers in the absence of any cure. The evidence of the overwhelming majority of past epidemics, for which there was also no known cure, seems to be, however, that medical treatment, even in the Middle Ages, could alleviate suffering under some circumstances, and was therefore a duty of the practitioner. In a condition that could prove rapidly fatal, the ethics of prolonged tests of a drug such as AZT, in which control groups were given placebos, was contested by AIDS sufferers anxious to try anything that might possibly cure the condition, or at least slow its progress.

If this was a relatively novel ethical problem, then the question of compulsory public-health measures was a very old one. Like the sufferers in many previous epidemics, AIDS victims tended to come from already stigmatized social groups: gays, drug abusers and prostitutes, Haitians and Africans. The ability to screen these high-risk groups for the presence of the causative agent, the HIV retrovirus, even at the asymptomatic stage, raised the possibility of compulsory screening measures, quarantine, and isolation. On the other hand, individuals publicly identified as HIV-positive generally found it difficult or impossible to stay employed, to obtain life or health insurance, or to avoid eviction from their homes. In the absence of adequate supportive measures, public-health intervention reinforces existing discrimination against these groups, as in many past epidemics.

An alternative state response has consisted of neglect, on the assumption that AIDS is unlikely to affect the heterosexual, non-drug-abusing, nonpromiscuous majority of the voting public. It is noticeable that, generally, politicians have invested resources in public education and other preventive measures only when they have believed that the majority population is at risk. These problems have been raised again by the recent resurgence of tuberculosis in Western countries, among the HIV-positive but also among the poor and the homeless. Drug-resistant strains of the disease have become common, and the transient, jobless, and destitute have neither the means nor the stability of lifestyle to complete the lengthy course of drugs that is necessary to effect a cure. The compulsory isolation of victims and their forcible subjection to a course of treatment is not a satisfactory long-term solution to the problem, since reinfection is likely upon release, unless the social and personal circumstances of the affected groups undergo a dramatic improvement.

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