Choices in Plague Time

In plague time, physicians learn firsthand the scale of an epidemic’s tragedy and horror. Less than ten years ago, I walked into the room of James, a young man my age who had a disease researchers were just beginning to call AIDS. Although AIDS appeared to be an infectious disease, the organisms that caused the disease and their method of spreading were still unknown.

I wondered if I might catch AIDS from James; I knew if I did I would die, for it was obvious that whatever caused James’s disease was one of the most virulent organisms I had ever read about or encountered. James’s system of defense against infection was being destroyed. He suffered from weight loss, fever, chronic diarrhea, and multiple infections.

Despite aggressive treatment, James died. Halfway through his hospitalization, when another terminally ill patient with AIDS was admitted to the ward, and then another, it was obvious that AIDS was more than a syndrome. It was a plague, a deadly epidemic disease. I went home every night like an ancient plague doctor, looking in the mirror with wonder because I had somehow escaped the pestilence.

This first encounter with AIDS forced me to make some difficult choices. They are choices we will each soon have to make, because AIDS is no longer confined to a case here or there; AIDS is an epidemic. The choices are really as old as plague itself. They are the choices of the ancient plague doctor and the enraged and baffled medieval citizenry. When finally confronted by plague, we can each choose to desert, to persecute, or to care.

Desertion

In the plague times of the Middle Ages, many Christians—including physicians and clergy—deserted the cities and their poor and dying inhabitants. And in the plague of 1665, historians note, most of the wealthy citizens and almost all of the physicians fled London. Nearly 70,000 of the 400,000 citizens died. And because of the mass exodus of physicians, official records indicate there were only 13 doctors to care for the more than 200,000 Londoners who remained in the city. (These doctors were on the public payrolls; we do not know how many private physicians continued to practice, but it seems likely there were very few.)

German and Italian physicians who remained to care for plague patients wore a distinctive outfit, complete with a beak filled with sweet-smelling substances to combat the stench of buboes and decaying bodies.

Desertion has also characterized some physicians’ responses to AIDS patients. Several physicians have stated publicly that they will refuse to treat them. Some families and some communities where AIDS patients live have been reluctant to care for them; and due to the high cost of care, and their inability to work, many AIDS patients have become impoverished. AIDS is increasingly becoming a disease of the urban poor and minorities. And while many physicians find AIDS “interesting,” the bulk of actual AIDS care falls on interns and residents in overburdened public hospitals.

As a medical resident, I trained in one such hospital. Like the plague doctors, I was under contractual obligations to care for AIDS patients, and I cannot claim an uncoerced willingness to treat patients like James. Like the Italian and German plague doctors, when we would go to see James, we would dress the part—gowns, masks, and gloves—and walk stiffly into his room. Our coats held no power of treatment, and no ability to cure. When James was dying, I sat at his bedside, the ragged tail of my coat trailing down to the floor; just so the medieval doctors must have sat by their patients’ bedsides.

The Consequences Of Desertion

The loss of the clergy, the physicians, the merchants, and their families, combined with the severity of the plague, resulted in the near-total collapse of medieval society. Disorder and violence were the rule; famine was common. Malnourishment resulted in diminished immunologic resistance, which made people more susceptible to plague.

The consequences of deserting AIDS patients are similar. In Central Africa, where one of ten people are infected with the AIDS virus, AIDS seems destined to disrupt societies that are already compromised by poverty, malnutrition, and other diseases. In America, while the situation is far less serious, our spiritual, physical, and financial desertion of AIDS patients may also result in a worsening of the plague.

Persecution

Saint Augustine, in The City of God, points to the tendency during plague time to assign blame and persecute the scapegoats. Robert Crawfurd, in Plague and Pestilence in Literature and Art, provides a frightening picture of the process:

“Amid all the panic of the Black Death, persecution of the Jews broke out with even greater ferocity than during the Crusades in the twelfth century. Some victim was needed to appease the maddened populace: so the Jews were accused of poisoning the wells, and even of infecting the air. Circumstantial accounts were circulated throughout Europe of secret operations directed from Toledo. The concoction of poisons from spiders, owls, and other supposed venomous animals was described.”

In Milan in 1630, two men—a barber-surgeon and the commissioner of health—were accused of spreading the plague by means of deadly ointments. The senate decreed that their flesh should be torn with red-hot pincers, their right hands cut off, their bones broken, and that they be put on the wheel for six hours, then burnt at the stake.

While such extreme reactions are unthinkable today, homosexuals and other groups at risk for AIDS have been accused of creating or importing the epidemic—not by using spiders and owls, but perhaps by way of Haiti or via contact with African green monkeys. There is no scientific evidence to confirm either of these vague, rumored accusations.

Groups at risk for AIDS have perceived mandatory AIDS testing as a form of persecution, and rightly so. There is ample evidence that upon learning one is an AIDS carrier, society will use modern means to persecute that individual. Those who test positive for the antibody will have difficulty obtaining jobs and buying insurance. As our indignant populace searches for scapegoats, the homosexual and the foreigner are the first ones we blame. Other AIDS patients—spouses, children, hemophiliacs—are considered more “innocent.”

Moves to quarantine all individuals who are AIDS antibody-positive actually arise from a persecution model. While the isolation of certain individuals who are knowingly spreading AIDS to multiple partners may be necessary, how exactly would we isolate the two million people who test positive for AIDS antibodies? How would we find them all? What about the false-positive tests, which are more likely than true-positive tests when the overall population has a low incidence of the disease? Where would we put all the antibody-positive people and how would we keep them from having sex?

The Consequences Of Persecution

In Toledo, where the Jews were persecuted as well poisoners, their accusers deceived themselves so thoroughly that Crawfurd tells us, “In many places the springs and wells were sealed, so that no one might use them, and the inhabitants of many cities had to rely on rain and river water.”

Besides sealing off their own water, the persecutors wreaked havoc on their own system of medical care, since many physicians were Jewish. Society was disrupted, public health measures were blocked, and the plague was made worse.

The consequences of modern persecution of homosexuals, drug abusers, prostitutes, and other “blameworthy victims” of AIDS are analogous: traditional public-health efforts to contain AIDS may well be hampered by fear of persecution. While actual cases of AIDS must be reported, there is currently no way to find and warn sexual contacts of AIDS patients or antibody-positive persons. This is not the public-health practice with other sexually transmitted diseases (STDS). The law requires that other STDS (such as syphilis) be reported to officials and that contacts be notified.

However, the lack of treatment for AIDS, its long incubation period of seven years (perhaps much longer), the large number of asymptomatic carriers, the high possibility of false-positive tests, and other factors create unique medical problems for reporting and tracing AIDS contacts. Mandatory contact tracing has been vetoed by the Centers for Disease Control for these medical reasons. Therefore, the prevention of future spread depends on the cooperation of risk groups whose fear of persecution will make such cooperation more difficult.

The choices to desert and persecute have similar consequences. The plague is likely to spread. Those who are at risk of plague may become disenfranchised. The persecuted groups, who could offer critical help and assistance during the plague, may be forced to flee or even to resist plague-control measures that unfairly single them out.

Compassion

Throughout history, there were notable and noble exceptions to desertion and persecution: Pope Clement VI extended his personal protection to the Jews at Avignon; the Emperor Charles IV did the same in Bohemia; King Casimir the Great, in a story that resonates with that of the Book of Esther, heard the pleas of a Jewish woman and granted sanctuary to Jews in Poland.

Some professionals went about their duties rather than deserting or persecuting the victims. William Boghurst, an apothecary, remained to care for patients during a severe plague in England. He deplored the desertion of those who could help attend the plague victims, and wrote that every man who is a professional must take the benefits and responsibilities together. Ministers must preach, captains must fight, physicians must attend to the sick.

In the eighteenth century, some Christians also chose duty and responsibility. During one of the first major plagues in the New World—a 1793 epidemic of yellow fever in Philadelphia—most of the citizens and physicians fled the city. Benjamin Rush, a Christian, remained, giving as his reason the duty to care for his patients even at the jeopardy of his own life.

Those of us who cared for AIDS patients in the beginning, when we didn’t know the method of transmission, did so at the perceived peril of our lives. Nurses, nurse’s aides, physicians, and other health-care workers were confronted with this choice back in the early 1980s, and most chose to stay and care for AIDS patients. As of this writing, nine health-care workers have been infected with AIDS by the blood of AIDS patients. The risk to health-care personnel is small compared to ancient plague doctors, but it is real.

The Consequences Of Compassion

Helping the victimized and caring for plague victims did not immediately eliminate the plague or prevent future epidemics. In the few plagues in which compassion was extended to the victims, the societies experienced less deterioration than they would have otherwise. The people did not lose all faith in the professions and institutions, including the church.

The consequences of compassion for AIDS victims and potential victims would also be positive in the long run. Knowing we will care for them instead of deserting or persecuting them, persons with AIDS will be more receptive to prevention strategies and more compliant with voluntary testing programs and even contact tracing. Blaming the victim results in embittered and uncooperative victims. Persecuting certain groups results in the loss of their vitally needed assistance.

Avoiding the assignment of blame makes sense in diseases that are truly plagues. After all, one of the future victims may be someone we know and love dearly. Will we not then want others to see him or her as a sufferer rather than a culprit? Did not someone hang on the cross, as victim, so that we would no longer need other victims, and have only ourselves to blame?

Every culture needs help in plague time, and Christians who understand compassion are in a unique position to help. America has not faced any major epidemic since influenza in the early 1900s and polio in the 1950s, and our citizenry is frightened, naive, and ill equipped to handle AIDS. The worldly sophistication our culture has so carefully cultivated comes up empty in the plague time.

The future of the AIDS plague will force us to make choices. Many may become increasingly enraged and baffled by the plague, and some may push for organized methods of desertion or persecution. In a dark world, where the plague “full swift goes by,” Christians are called to be salt and light, to model compassion, and to take risks. We seek to be like him who touched lepers and prostitutes, who took the blame, who bears the stigma.

Clinical Notes Of A Former Pharisee

As a clinician, I know that AIDS is a complex, ongoing problem that will not be eradicated even by maximal use of latex barriers and other stopgaps. AIDS has a foothold in every population group—including heterosexuals, children, and the elderly.

Understanding AIDS, in the end, requires knowing someone with the disease. The lessons I learned from caring for James are still the most meaningful:

AIDS is a disease that affects the entire body, and like other diseases gains entrance at a vulnerable area. At first I tried to dismiss James’s disease as somehow different from other diseases because he acquired AIDS through promiscuous homosexual activity. But as I saw what AIDS did to him clinically—causing him to lose a third of his body weight, destroying his immune system, infiltrating his brain—I realized that AIDS is like other diseases. Human beings will get it because human beings are in contact with one another and are vulnerable to disease. Human beings will get AIDS just like they contracted polio or influenza, leprosy or syphilis, tuberculosis or bubonic plague—from one another. When this plague passes, another will come, with different initials and with a different mode of transmission; but as long as there are people, there will be diseases and plagues.

AIDS is a disease that appeals to Pharisees. One of my first thoughts, when I began taking care of James, was to thank God that I was not like him. And then I remembered the moral Jesus added at the end of the parable of the Pharisee and the publican: “Every one that exalteth himself shall be abased; and he that humbleth himself shall be exalted” (Luke 18:14).

When we begin by despising others in our hearts—by thinking ourselves righteous in comparison to them—we prove Jesus’ words true. I began my treatment of James with the attitude of a Pharisee, thanking God that I was “not as other men”; I tried to see his disease as somehow different from other diseases; I did not consider the possibility that this stigmatized man had repented and had been forgiven while I was yet in my sins. In my heart, I approved of his suffering and inevitable death.

I count all these sins equal to his—no, much greater, according to Jesus. I have been able to repent, and to change my mind about AIDS and AIDS patients. I feel the struggle of plague time within me, and realize the parallels between AIDS and other plagues. Then I remember the story of the Pharisee and the tax collector, the one about the self-righteous plague doctor and the homosexual AIDS patient.

David L. Schiedermayer is visiting scholar and fellow at the Center for Clinical Medical Ethics, Pritzker School of Medicine, the University of Chicago. This paper is expanded from a convocation address presented at Judson College (Elgin, Ill.). The opinions expressed are the author’s and do not necessarily represent those of the institutions with which he is affiliated.

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