Book Review

How to Have Theory in an Epidemic: Cultural chronicles of AIDS

N Engl J Med 2000; 343:1343November 2, 2000

Article

How to Have Theory in an Epidemic: Cultural chronicles of AIDS
By Paula A. Treichler. 477 pp. Durham, N.C., Duke University Press, 1999. $22.95. ISBN: 0-8223-2318-4

The idea that the responses of individuals and organizations to diseases are shaped by culture is not as controversial as it once was. The great therapeutic innovations in medicine surely stem from the concept that science is insulated from social forces, but the ways in which social and cultural forces can influence science and medicine are increasingly familiar. The way in which the story of the human immunodeficiency virus (HIV) and AIDS has unfolded over the past two decades is becoming an important topic of study by social and cultural theorists, because it provides so many examples of illness as a cultural phenomenon with individual, social, and political ramifications. Changes in the ways in which we understand homosexuality and sex, the rise of efforts to empower patients, and the increase in activism have been spurred by AIDS. In How to Have Theory in an Epidemic: Cultural Chronicles of AIDS, Paula Treichler has made an important new contribution to this young field.

The cultural chronicles presented in this book are essays written during the past decade; they describe and explain the many themes that emerge in popular depictions of HIV and AIDS. Because the chapters and essays were conceived separately, the book does not have a cohesive focus. This could be seen as a weakness by some, but, in fact, the format makes what could be a dense treatise more readable. Furthermore, the thesis that the AIDS epidemic has cultural and linguistic as well as biologic and medical aspects is well illustrated in the book.

One example is the way in which the television industry first faced the problem of depicting AIDS during the politically conservative mid-1980s. In her essay “AIDS Narratives on Television,” Treichler analyzes two of the earliest efforts to deal with AIDS: An Early Frost, first broadcast by the NBC network in November 1985, and Our Sons, broadcast by the ABC network in May 1991. As Treichler sees it, these dramas dealt with the challenge of presenting homosexuality to prime-time audiences (and advertisers) largely by focusing the narrative away from the gay characters with AIDS and instead emphasizing the effects of the illness on their heterosexual relatives. This strategy helped steer the producers toward the admirable goal of showing gay relationships with unprecedented candor. But Treichler rightly stops short of being too congratulatory; after all, these movies managed to present their stories without once mentioning condoms or safe sex at a time when hundreds of thousands of Americans were infected with HIV.

The author is at her strongest in discussing the ways in which culture and the media have shaped the public's understanding of who is at risk for infection with HIV. The attribution of epidemic diseases to “outsiders” or to socially marginalized groups is common and is a familiar theme in descriptions of social responses to syphilis, plague, smallpox, and of course, AIDS. These attributions are responses to social and cultural forces, and are often not based on epidemiologic evidence. Depictions of HIV as imported to the United States from Haiti or from Africa have parallels within Africa itself, where Malawians may identify Mozambicans as sources of infection, and vice versa. Ironically, the notion that AIDS was a problem of socially marginalized groups contributed to dramatic depictions by the media later in the epidemic, as reflected by a famous Life magazine cover story in July 1985 (“Now No One Is Safe from AIDS”). As Treichler correctly points out, the presentation of both extremes caused inaccurate perceptions about the real public health message: that the risks of HIV are associated with behavior rather than demographic characteristics.

The methods of the historian seem to work poorly in the absence of a detachment from the periods and places being described. Because of this, many of Treichler's histories offer few new ideas and do not provide a context for their subjects. Nevertheless, even though it is not a work of historical scholarship, How to Have Theory in an Epidemic provides much of the insight into events that we might otherwise look for in cultural histories of the HIV epidemic published years from now. The author's scholarship spans the media, from high art to comic strips, from Philadelphia to General Hospital, and from National Geographic and Newsweek to Morbidity and Mortality Weekly Report. The book is meticulously footnoted and largely (though not entirely) free of jargon specific to the academic field of cultural studies. Some will find a few passages slow going. This book is an important addition to the growing literature analyzing illness — and the HIV epidemic — from social and cultural perspectives, and it will be appreciated by many.

Allen L. Gifford, M.D.
Veterans Affairs San Diego Healthcare System, San Diego, CA 92161