The Intimacies of Strangers

The enchanting child smiles mischievously at the camera. He feels great, he tells the reporter, and attributes his swift recovery to ice cream. His age and status vary with the headlines: he is four or five, and he is or may be “Patient Zero” of the “swine flu” outbreak of 2009. His mother worries about the epithet; she is afraid he will be blamed and stigmatized. But her worry is unnecessary. He is Édgar Hernández of La Gloria, Mexico; he has survived a bout of H1N1 influenza, and he is not Patient Zero. Édgar Hernández is a cherubic Mexican boy; Patient Zero is a monstrous stranger, the protagonist of what, in Contagious, I call “the outbreak narrative.”[1]

The term “patient 0” entered public circulation with the journalist Randy Shilts’s 1987 account of the early years of the HIV epidemic in the United States, And the Band Played On. The term Patient Zero refers to the index case of an epidemiological study; Shilts explains how CDC (Centers for Disease Control and Prevention) researchers kept encountering the name of a gay French Canadian flight attendant, Gaetan Dugas, when they asked for the sexual contacts of the earliest cases they were investigating. Epidemiologists and medical researchers suspected that there might be a communicable disease underlying the mysterious syndrome and that it might be sexually transmissible. But they needed proof. The handsome flight attendant appeared on the lists of sexual contacts of people with AIDS in several locations, so CDC investigators made him “patient 0”—the index case, or starting point of the epidemiological investigation—and made a chart of his contacts. While the evidence supported the hypothesis of sexual transmission, it did not indicate where or in whom the disease might first have appeared.

Patient Zero was a narrative as well as an epidemiological device. The French Canadian flight attendant allowed CDC epidemiologists to test a hypothesis and to tell a convincing story about the etiology and transmissibility of the mysterious syndrome. As Patient Zero, the figure also allowed Shilts to write an “outbreak narrative” about the epidemic: a conventional story about a species-threatening communicable disease that draws on the drama of the detective story and the horror story as it turns on an apocalyptic battle between microbes and agents of transmission on one side and scientific medicine and epidemiology on the other. The narrative arc of the story begins with the appearance of a deadly communicable disease, chronicles its spread as well as the efforts of heroic epidemiologists and medical researchers to identify and contain it, and concludes with their success and with a celebration of the victory, once again, of science and medicine over the microbe and its agents of transmission.

The outbreak narrative is a social as well as a medical story, chronicling the networks and ecologies of a shrinking globe and the strangers who circulate through them. The outbreak narrative also has an identifiable geopolitics, with infection beginning in the jungles or “teeming cities” of the global South and spreading into the metropolises of the global North. It is an updated version of what Lisa Lowe calls “global intimacies”: the spatial proximities, the personal, social, and economic relationships that generated the knowledge categories of modern humanism as well as the “modern racialized division of labor.”[2] Setting her account in the context of the Enlightenment, Lowe demonstrates the centrality of such Chinese immigrant figures as “the Chinese coolie” and “the Chinese woman” to the articulation of the human in this moment of modern/ist inception. Patient Zero is a latter-day incarnation of these figures: an embodiment of intimacies (in all of its meanings) that produce knowledge, classifications, and divisions of labor—all racialized. The flight attendant is the foreigner, the stranger, whose foreignness distinguishes him. He stands out to the CDC investigators and allows them to chart relationships that tell the story of disease transmission as well as global intimacies: networks of proximities, social relationships, and sexual liaisons marked by the destructive power of the microbe, but circulated through the aberrant behavior of its carrier.

Patient Zero has an obvious precedent in the most notorious carrier in medical history: the Irish immigrant and domestic servant Mary Mallon, better known by her infamous epithet, “Typhoid Mary.” Shilts calls Dugas “the Québecois version of Typhoid Mary,” and both figures are routinely summoned in media accounts of every threatened outbreak.[3] Like Dugas, Mallon was central to the demonstration of a medical scientific and epidemiological hypothesis: in her case, the theory of the healthy carrier of a communicable disease. The healthy carrier is someone who can transmit a disease without appearing ill or even, as in the case of Mallon, having been ill with the disease. With Mallon’s identification, researchers could demonstrate the existence of such carriers, which was arguably the cornerstone of the emerging field of public health.[4] Social interactions and relationships changed accordingly, as everyone became a potential source of infection, but accounts of Mallon stressed her foreignness and abjection: as an Irish immigrant, a domestic servant, and an assertive and sexually active unmarried woman, she embodied the allegedly dirty, dangerous stranger (immigrant) who was circulating in increasing numbers in the early 20th century United States.

Communicable disease manifests the intimacies of strangers. It is transformative: the son, the sister, the lover infected and inflected—converted—by global intimacies. The instrument of communicable disease is the microbe, and its animation is virtually irresistible in specialist as well as mainstream science publications and in popular fiction and film. The healthy carrier and its offshoot, Patient Zero, are its incarnations: evidence of the metamorphosis and of the agency of the microbe. Writers have exploited the dramatic potential—and unearthed the implications—of these figures in human agents who metamorphose into something more or less than human, such as the hybrid virus/human protagonist of Chuck Hogan’s 1998 epidemiological horror novel, The Blood Artists.

As in Lowe’s formulation, these figures are the sources of the production of knowledge—medical, scientific, epidemiological, and geopolitical—which is both racialized and spatialized. The geography of communicable disease follows a geopolitical logic, moving from the global South to the global North, while expertise moves in the opposite direction. Hence, media sources have Dugas (who, according to Shilts, had not been to Africa) bringing “African AIDS” to North America, while the Dark Continent (this according to Shilts) looks to the United States for salvation from the species-threatening epidemic.

If Patient Zero gives a human face to communicable disease, it is the face of the stranger caught in the process of change. Part human, part animated virus, Patient Zero is also the stranger within. For the German sociologist Georg Simmel, estrangement marked not the distinction between self and stranger, but an uncanny familiarity. Estrangement replaces the sense of uniqueness, unleashed with the recognition of the self in the stranger. It marks the dissolution of boundaries as a group begins to expand.[5] The moment of becoming is frozen in Patient Zero at, in ecological terms, the stage of struggle that precedes conquest or accommodation.

As a figure of change, of categorical confusion, Patient Zero has to become monstrous. Shilts’s archetype cares only about sex and vengeance. He becomes the source of an urban legend as accounts spread of “a strange guy at the Eighth and Howard bathhouse, a blond with a French accent. He would have sex with you, turn up the lights in the cubicle, and point out his Kaposi’s sarcoma lesions. ‘I’ve got gay cancer,’ he’d say. “I’m going to die and so are you’” (Shilts, 165). Typhoid Mary was similarly depicted not just as recalcitrant, but as deliberately sowing destruction, as a “human culture tube” intentionally spreading “the disease wherever she goes.” They embody the spirit of dangerous promiscuity infused with global intimacy: the ultimate queer challenge to familiar (and familial) social structures and the unchanging future they promise. Their dangerous transmissions literally threaten the species, and their circulation marks the threat of social and sexual promiscuity on a global scale. Writing in Vanity Fair about “African AIDS” in 1988, Alex Shoumatoff mused “about the unprecedented merging and mixing and growing together of the world’s population in the last few decades, the tremendous release of people from their traditional confines, the enormous flow from the villages to the cities of the Third World to the immediate outskirts of New York, London, Paris, Rome, Cologne, Marseilles.”[6] Infected travelers—carriers of HIV—pose the threat of porous borders, of too much democracy. Against that threat, epidemiologists and medical researchers struggle to save the species from its manifestation in communicable disease. In the context of the outbreak narrative, the human carrier and its incarnations ultimately embody not only the threat but also the promise of containment.

It was not, however, epidemiologists who christened Édgar Hernández “Patient Zero.” It was, rather, residents of his village in La Gloria, Mexico who sought not to target their native son but to indict the nearby “American-owned industrial pig center,” which, as science writer Laurie Garrett reports, had long been the source of residents’ complaints “about the stench and dust from the plant.”[7] Angry about the impact of globalization on their town, residents of La Gloria sought to fashion their own narrative of blame. It is not surprising that they would turn to Patient Zero to do so. That figure and its earlier incarnation, the carrier, conventionally evoke a complicated story of incrimination and stigmatization.

There are many reasons that the story of a Mexican Patient Zero did not work. The H1N1 virus does not seem (at this time, May 2009) to be especially virulent and is certainly not a species-threatening event. Nor is Édgar Hernández a Patient Zero. Although he tested positive for the virus, the source of his infection remains unclear, and no one seems to have contracted it from him, even the members of his family with whom he shares a bed. He cannot therefore be the index case either of the disease or of an epidemiological study of its transmission. He is the face of innocence and promise: the boy who stayed within the confines of his village, spread the disease to no one, and recovered thanks to the healing power of ice cream.

The effort to transform Édgar into Patient Zero nonetheless demonstrates the power of the outbreak narrative. Sounding the alarm of a species-threatening event, it inflects the networks of a shrinking world with the danger of a deadly communicable disease. The outbreak narrative defines the global intimacies—the proximities and relationships—that constitute a geography of disease. It defines who/what is a threat and who/what is at risk. In so doing, it exacerbates the very global inequities—the poverty and exploitation—that the residents of La Gloria sought to expose. Those inequities, moreover, fuel pandemics, since poverty and inadequate health care are its most potent vectors. If H1N1 is, as some medical experts suggest, a dress rehearsal for the predicted global pandemic, we would do well to consider how the outbreak narrative might be helping to set the stage.

Priscilla Wald es profesora de Inglés en la Universidad Duke y autora de Contagious: Cultures, Carriers and the Outbreak Narrative (Duke UP, 2008). Es editora de la revista American Literature.


[1] For a more detailed discussion of the “outbreak narrative,” “Patient Zero,” and “Typhoid Mary,” see my Contagious: Cultures, Carriers, and the Outbreak Narrative (Duke University Press, 2008).

[2] Lisa Lowe, “The Intimacies of Four Continents,” in Haunted by Empire: Geographies of Intimacy in North American History, ed. Ann Laura Stoler (Durham: Duke University Press, 2006): 191-212, 192.

[3] Randy Shilts, And the Band Played On: Politics, People, and the AIDS Epidemic (New York: St. Martin’s Press, 1987), 157.

[4] On the relation of Mallon to the emergence of public health, see Judith Leavitt, Typhoid Mary: Captive to the Public’s Health (Boston: Beacon, 1996); Andrew Mendelsohn, “’Typhoid Mary Strikes Again: The Social and the Scientific in the Making of Modern Public Health,” Isis 86.2 (June 1995): 268–77; and Nancy Tomes, The Gospel of Germs: Men, Women, and the Microbe in American Life (Cambridge, MA: Harvard University Press, 1998).

[5] Georg Simmel, “The Stranger,” The Sociology of Georg Simmel, ed. and trans. Kurt H. Wolff (New York: The Free Press, 1950), 402–08.

[6] Alex Shoumatoff, “In Search of the Source of AIDS,” Vanity Fair 51.7 (July 1988): 94–105 and 112–117, 117.

[7] Laurie Garrett, “The Path of a Pandemic,” Newsweek (May 11/May 18, 2009): 22-28, 26. The pig farm is actually a joint venture between the U.S.-based Smithfield Foods, Inc. and the Mexican firm Agroindustrias Unidas. “Typhoid Mary” makes an appearance as well in the person of Maria Adela Gutierrez, a census taker who, according to MailOnline was “the first swine flu fatality…who may have come into contact with at least 300 people when the virus was at its most infectious” and who “may have caused a pandemic.” There is no evidence to support these claims, but the story has circulated in the blogosphere.