246 A HISTORY OF AMERICA IN 100 MAPS
In 1985 Abraham Verghese began to practice
medicine in Johnson City, a town of 50,000 near the
Great Smoky Mountains in Eastern Tennessee. As an
infectious disease specialist, he had learned about
acquired immune deficiency syndrome (AIDS) during
his medical residency in Boston. But in the mid-1980s
Verghese—like most Americans—considered AIDS
primarily an urban epidemic, and hardly thought that
he would encounter the disease in rural Tennessee.
Nonetheless, soon after arriving in town he began to
reach out to the gay community to promote voluntary
HIV screenings, and was heartened to find that local
men tested negative for the virus.
Within three and a half years, however the
situation had shifted dramatically. Verghese had
treated eighty-one HIV-positive patients, thirteen
of whom died from AIDS. He could not understand
why so many men were falling ill given that the
locals continued to test negative for the virus. In
search of an explanation, he began to wonder if
there was a geographical pattern at work. At home
one evening, he took down a map from the wall of
his son’s room and began to mark the residence of
each of his patients. As shown on the lower map, he
found that they clustered around Johnson City, but
also extended to Southwest Virginia and Kentucky,
the farming towns of Eastern Tennessee, and even
the mountains of North Carolina. This was to be
expected, since his hospital served a large and
geographically extensive area. But the number of
cases was still far higher than what the Centers for
Disease Control and Prevention would have predicted
for a rural region. What accounted for this?
Turning back to the map, Verghese then identified
where each of his patients had lived between 1979
and 1985, when they most likely contracted the virus.
On the upper map, a pattern began to emerge: by
and large, his patients were raised around Eastern
Tennessee, but as adults had moved to urban areas
around the country in search of opportunity and
tolerance. From this he hypothesized that most of
THE TERROR OF AIDS
Abraham Verghese, Steven L. Berk,
and Felix Sarubbi, HIV infection across
the US, and around Johnson City,
Tennessee, 1989
them had contracted the virus in the city; those
who had never left the area had probably become
infected by engaging in high-risk activity locally
or by receiving blood transfusions before HIV testing
was routine.
Taken together, these two maps showed Verghese
a pattern of migration that explained the sharp rise of
rural HIV cases: most of his patients had moved home
to seek care and support once they began to exhibit
symptoms of AIDS. Verghese’s medical expertise gave
him the tools to diagnose the disease, but only by
mapping the movement of his patients did he realize
the implications it would have for the region and his
practice. As patients came home with the illness,
families would become crucial networks of care. And
if Johnson City’s experience was typical, then rural
medical centers all over the country would need to
prepare. Rural rates of infection remained far lower
than urban, but AIDS devastated families everywhere.
Verghese’s maps and research were published
in the Journal of Infectious Diseases, which itself is
revealing. Previously, the journal had typically
focused on the large centers of the epidemic in
urban areas. Yet as Verghese stressed, HIV infection
presented unique problems for rural communities.
For one, the stigma of the virus remained higher in
rural areas. And because incidence of the disease was
lower, rural communities might be less prepared for
its inevitable rise. Verghese found that families of
his patients in Johnson City almost invariably rallied
around their loved ones, challenging assumptions
about rural attitudes toward homosexuality. Yet
at the same time, he stressed the need for rural
communities to mobilize in order to anticipate the
inevitable rise of HIV infection.
While Verghese was treating patients in Eastern
Tennessee, the geographer Peter Gould was in
Pennsylvania researching the national scope of the
epidemic. Gould was particularly frustrated by the
failure of medical professionals to understand—and
thereby address—the geographical dimension of
this public health crisis. Even the epidemiologists
who specialized in the virus made little effort to
understand its spatial distribution. To address this,
Gould painstakingly gathered data from different
agencies around the country to trace the evolution of
the disease across the nation. The maps on the next
page showcase Gould’s adoption of digital techniques
to capture the geographical dynamics of the epidemic.