Herpedemic

Almost every year some new disease becomes a focus of prurient, even voyeuristic attention on the part of the British public. The choice seemingly depends more on the whims of fashion than on the importance of the disorder for public health. In 1983 the headline-maker is herpes, a virus infection of the genitalia that is neither new nor especially common, but since 1980 has been the subject of unprecedented coverage on television and in print in the United States. Fashions of this kind rarely last more than a year or two – who now remembers or is much concerned about Lassa fever or legionnaire’s disease? The herpes hype may, however, be rather more important than some of its predecessors, since the fears, anxieties and guilts it generates have quite devastating effects in individual cases.

Quite how a disease becomes a talking-point is not known: interest in pop stars, new foods, new diets or leisure activities, can be manipulated for commercial reasons, but no one is likely to make money from a surge of interest in a disease. Sometimes – as with legionnaire’s disease and now with herpes – Britain follows a year or so behind the United States. Sometimes the Americans pick up and develop an issue first publicised in Britain, as with the recent withdrawal from the market of the anti-rheumatic drug Opren. On other occasions – the campaign about the safety of the whooping-cough vaccination is an example – concern in Britain has no impact in the United States. Finally there are many instances of the British remaining immune to American hysteria, as in the case of the so-called cancer cure laetrile, which became big business in the United States but has had no impact in Britain – probably because here most cancer is treated in NHS hospitals and people do not believe they can buy cures.

No one can yet say which pattern will be followed in the case of genital herpes. The Americans are already in the grip of a sustained frenzy of herpes hysteria: in Britain the public reaction has been less dramatic (perhaps because fewer Britons are prepared to bare their sexual souls in public), but each week sees another broadcast, newspaper article or magazine feature on the topic. How much of this crescendo of interest is warranted? Is there an epidemic of herpes? Should it be described as ‘the only venereal disease for which there is no cure’? Will the risk of herpes lead to widespread changes in sexual attitudes and behaviour? Certainly many of the articles and television programmes in the United States in 1980-82 concentrated on the alleged effect of herpes on sexual behaviour – with some individuals claiming that casual sexual encounters were now ‘too risky’ and that the permissive society was over. Scary statistics were circulated, with suggestions that as many as 20 per cent of all young Americans had had an attack of herpes.

The reality is much less alarming. Herpes is not a new, or recently discovered, or unknown disease, nor is it sweeping through the populations of Europe and North America like one of the plagues of Egypt. In Britain it is one of the less common of the sexually-transmitted dieseases – between ten and 12 thousand patients with herpes are seen each year in hospital clinics, as compared with 60 thousand with gonorrhoea and 130 thousand with non-specific urethritis. True, ever since the Second World War all the sexually-transmitted diseases have been more common in the United States than in Britain, but in both countries these diseases are still found mostly among prostitutes and their customers and in homosexuals: for most of the population herpes remains a remote possibility.

Dr J.K. Oates, an experienced venereologist, is therefore able to be reasonably reassuring in his Penguin guide to herpes. Part of the explanation for the current rash of fears and misconceptions is that herpes is a complicated disease and until recently one that was rarely mentioned in popular books on venereal disease. Dr Oates tells us that when he was writing some leaflets on venereal diseases twenty years ago he wrote only eight lines on herpes. Since then, much has been learned about the disease, but the big change has been in public awareness of its existence. Since 1980, says Dr Oates, ‘it has caused and still causes many of my patients more anxiety and unhappiness than any other, and in my opinion much of this load of worry is, in the majority of cases, quite unnecessary.’

Indeed in its more usual, non-sexually-transmitted form the herpes virus is familiar to all of us and not at all frightening: it is the cause of cold sores (fever sores, cold blisters) – the blisters that many people get on and around the lips during an attack of influenza or any other respiratory infection. Some people find that they have one or more cold sores whenever they have a bad cold, and they may also get an attack after exposure to bright sunlight (as on a skiing holiday). The sores start as little blisters which then burst to form painful sores or ulcers; scabs eventually form and the sores heal, the whole process taking ten days or so. Everyone knows a few individuals who have recurrent attacks in their lifetime.

Cold sores are caused by an organism called herpes virus I. Similar painful blisters may form on the genitalia, but these are usually caused by a very slightly different virus, herpes virus II. (The two are so similar that occasionally cold sores may be caused by herpes II and genital herpes by herpes I.) Like herpes affecting the face, the genital infection usually lasts for five to 14 days, at the end of which time the sore spots heal and the symptoms disappear, though the disease may be transmitted to a sex partner for some days before and after the illness as well as during the attack. And just as some unlucky individuals have recurrent attacks of facial herpes, so some men and women have recurrent attacks of genital herpes. The size of this risk is difficult to estimate, but Dr Oates estimates that between 40 and 70 per cent of adults who have had an attack of genital herpes will have one or more recurrent attacks. Many adults, however, never have an attack despite exposure to the virus: such people can be shown to have developed effective immunity during a symptomless, inapparent infection at some time in the past. Herpes resembles many other viruses (the polio virus is an example), in that infections during childhood may cause virtually no illness at all but will provide long-lasting immunity. So by no means everyone who has sexual intercourse with a partner who is infected with herpes will ‘catch’ genital herpes. Anyone who does have an attack of herpes is quite likely never to have another; recurrent attacks tend to become less frequent and less severe.

Why, then, has there been such an amazing brouhaha about an uncommon virus infection which usually clears up without causing any complications? Sinister stories about herpes probably began to develop in the mid-Seventies as part of a more general concern about the growing problem of sexually-transmitted diseases, in itself a reaction to the sexual liberation that occurred in the Sixties, as the combination of reliable contraception and the legalisation of abortion freed women of the worry of unintended pregnancy. The two classic venereal diseases, gonorrhoea and syphilis, were both easily cured by penicillin. Unlike their parents, teenagers growing up in the Sixties could not be warned off sexual activity by talk of ‘medical risks’. By the Seventies opinion had changed: sex was no longer believed to be free of hazard. As more people adopted a way of life that included frequent changes of sexual partner, sexually-transmitted diseases became more common (both in Britain and in the United States). The main increases were not in the old, familiar diseases, gonorrhoea and syphilis, but in less clearly defined infections with organisms such as chlamydia, candida – and herpes. More important was a growing awareness that even in the era of antibiotics some of these diseases had sinister implications. Women who became infected with chlamydia (or gonorrhoea) could be cured of the acute infection but might be left sterile as a result of damage to their internal organs (previous genital infection accounts for something like a third of all cases of infertility in women). So-called non-specific urethritis could occasionally precipitate a form of arthritis, Reiter’s disease, which could cause progressive crippling. Most recently, the ‘gay compromise syndrome’ – a complex mix of infection, cancer and disordered immunity found almost exclusively in homosexuals – has claimed several hundred lives, mostly in the gay communities in New York and on the West Coast of the United States, but also in Europe. These negative aspects of sexual permissiveness have provided ammunition for campaigners pushing for a return to traditional morality, who have sometimes exaggerated the risks of sexually-acquired infections. In the case of herpes, for example, women have been warned that if they have an attack of herpes during pregnancy they may miscarry or the baby may become infected during the process of birth and develop a dangerous and potentially fatal brain infection. In reality, in Dr Oates’s words, expectant mothers ‘can nearly always be given a 100 per cent reassurance that they and their baby will come to no harm as a result of this infection.’ Much the same applies to herpes and cancer. Most – but not all – women who develop cervical cancer can be shown to have been infected with herpes virus II at some time, but the evidence linking the virus with cancer is far from conclusive. In practical terms, any woman who has regular cervical smear tests will have any tendency to cancer detected early enough for it to be cured.

Sadly, the publicity has painted such a black picture of herpes that anyone who now has a first attack of the disease may believe that they will never be free of it and will have to cut themselves off from sexual contact with the ‘healthy’ world. Such a belief is, as we have seen, quite false. Very possibly the attack will be a solitary episode; if the disease does return, the victim will be infectious only briefly. The herpes bandwagon will nonetheless continue to roll, but here in Britain we may hope to avoid the hysteria that has been seen in the United States. NHS clinics for sexually-transmitted diseases provide an effective, non-judgmental service of a kind not available in most parts of North America. Dr Oates and Penguin Books have done their best to demythologise herpes, putting it back into perspective as a relatively uncommon, not especially sinister disease which few of us are likely to encounter.