December 15, 2020

Disease is no democrat. As 2020 has demonstrated. This year has made us all part of a vast data-collection project that will, when computed, reveal Covid-19’s favourites and perfect victims, its disproportionate wrath. We already have the preliminary findings.

Black Britons and poor Britons have suffered the most. This could be a propensity of the Coronavirus, but it might simply be a function of the contemporary United Kingdom, where living in the richest areas of the country buys you almost 19 more years of life than if you lived in the most deprived. If the Victorian researcher Charles Booth were to rise from the grave to draw us some new poverty maps, he’d still need all those different coloured inks.

One ailment, though, maintains a reputation for discriminating against the wealthy. Gout makes big toes swell painfully and cartoonishly. It causes chalky nodules called tophi — often compared to crustacean eyes — to balloon from knees and knuckles. It hurts. (“Like walking on my eyeballs,” reported the Regency cleric and humourist Sydney Smith.) The condition occurs when excessive amounts of uric acid in the blood cause crystalline needles of salt to gather in the joints and surrounding tissues. Its raw materials are purines — chemical compounds thickly concentrated in seafood, meat and alcohol — which helps to explain why gout gained its status as “the disease of kings.”

“Gout,” concluded Thomas Sydenham, one of the founders of British clinical medicine, “kills more rich men than poor, more wise than simple.”

Three centuries later, that’s no longer the case. The last big British study found that prevalence of gout in the population had increased by over 60% between 1997 and 2012. (Wales and the north-east of England were particularly afflicted.) In US, the “gout therapeutic market” is valued at $1847m, and a report released last month projected it might reach $3820m by 2027.

Thomas Sydenham might have looked at these figures and seen a strange and painful kind of social progress; a pathological levelling-up. In his day, only the wealthy could afford to surfeit on lampreys, pate and port. Perhaps, in 202o, cheap meat, cheap booze, the Iceland prawn ring and the two-metre long Aldi pig-in-a-blanket have made gout a disease to which anyone can aspire.

The history of gout is as much about culture and class and morals as medicine. It’s a deep and uncomfortable history. Papyri discovered in the 1910s showed that the Egyptians had identified the condition by 2640 BC. In the 5th century BC, the physician Hippocrates referred to it as “the walking disease”. The name by which we know it calls back to the humoral theories of human biology that persisted from Ancient Greece to the early modern period. It comes from the Latin gutta (“drop”), and was first recorded by the 13th century by the French historian Geoffroi de Villehardouin, who asserted that the crusader Hugh IV of Saint-Pol had expired at Constantinople in 1205 because too much fluid — black bile, yellow bile, or phlegm — had spilled down into his legs.

Despite such horrors, gout conferred a kind of blessing. It was rarely fatal, and its presence in the body was thought to keep other, more deadly conditions at bay. “It prevents other illnesses and prolongs life,” argued Horace Walpole, “Could I cure the gout, should not I have a fever, a palsy, or an apoplexy?”

Surprisingly, for a condition that can turn your joints into throbbing satsumas of flesh, it was even considered sexy. Gout talk added a frisson to Benjamin Franklin’s flirty correspondence with Anne Louise Brillon de Jouy, a married harpsichordist he met in Paris in 1777. Franklin teased Brillon that had they consummated their relationship, his feet might be less painful in the night. (“If the ladies at Passy had more of that Christian charity which I have so often recommended to you, in vain, I would not have the gout now.”) She responded with a poem proposing the opposite: a man with “a pretty Mistress” — or two, or three, of four — was more likely to suffer. Franklin’s reply was to stay up late writing a short two-handed comedy in which the personification of his condition, Madame Gout, visits him in his chamber, rather as Fortune visits Boethius in Consolations of Philosophy.

Novelists and politicians no longer feel the compulsion to turn their uric tortures into light literature. Despite the rise in cases, the discourse of gout has all but disappeared. And yet, the moral ideas that have circulated it since ancient times — its association with excess and indulgence — are still legible. They’re there, for instance, in Yorgos Lanthimos’s 2018 film The Favourite, in which the agonies suffered by Olivia Colman’s Queen Anne are attributable to her predilection for self-pity and stuffing herself with massive slices of cake. We see her engorged legs swaddled and smeared in therapeutic unguents. (We’re not told what these are, but one traditional remedy is advised: “Roast a fat old goose and stuff with chopped kittens, lard, incense, wax and flour of rye. This must all be eaten, and the dripping applied to the painful joints.”)

The outgoing Republican administration, though, should be given some credit for reviving gout as a moral metaphor — via the story of Paul Manafort, the disgraced chair of Trump’s 2016 election campaign. Manafort was convicted in August 2018 for lying his way to securing bank loans and evading taxes on the $16 million he earned as a lobbyist for pro-Russian politicians in Ukraine. His trial produced evidence of a fraud-funded life of eye-watering excess. His $15,000 ostrich-leather bomber jacket became a court exhibit. “The gluttony,” reflected the fashion critic of the Washington Post. “The indulgence. The preening bad taste.”

When he appeared for sentencing in October, he rolled into court in a wheelchair. His body was clad in a green prison jumpsuit labelled “ALEXANDRIA INMATE”, but his right foot was wrapped in bandages. His attorneys used his gout diagnosis as part of a plea for mercy. The judge, passing sentence the following March, was unmoved. “It is hard to overstate the number of lies and the amount of fraud and the extraordinary amount of money involved,” said US district judge Amy Berman Jackson. Manafort’s lies to Congress and to the American people, she observed, were perpetrated “not to support a family, but to sustain a lifestyle that was ostentatiously opulent and extravagantly lavish – more houses than a family can enjoy, more suits than one man can wear”.

Manafort sat in his wheelchair and listened in silence to the judgement. He wore a sober suit. His right foot remained bandaged. Its swollen condition became part of the story. Gout as an indicator of corruption? Gout as karma, perhaps?

Too easy. Too satisfying. Champagne and foie gras can exacerbate an attack of gout, but if Manafort is a typical case, his condition is probably genetic. People who live on nut loaf and tap water are not immune and know its nocturnal agonies. The rise in gout’s prevalence in the UK and the US can’t be mapped onto any growth in the sale of purine-rich luxuries. Something more complex is happening.

Obesity is rising. The population is ageing. There are more people alive today in gout’s high-risk groups than there were in the days of Sydenham and Walpole. Let the law punish Paul Manafort, not the cultural backstory of the uric crystals giving his foot the Little Mermaid treatment. And let it bring justice for those others, too, who are enduring illness associated not with privilege, but its opposite.