The killer that knew no borders

Disease and Democracy
February 24, 2006

When Aids first appeared in North America and Europe in the early 1980s, historians played an important role in determining the liberal policy response that some countries adopted. In a classic public health struggle between the rights of the individual and the good of the community, they drew lessons from the history of responses to sexually transmitted disease in particular, and argued for a non-punitive policy line.

Peter Baldwin's book acknowledges those earlier contributions, but his historical argument is different. Building on his earlier, and widely admired, book on European public health in the 19th and early 20th centuries, Contagion and the State in Europe, 1830-1930 (1999), he surveys responses to Aids in Europe and the US, arguing that the "surprising differences" in the way states responded to the epidemic had their origin in the public health traditions that held sway in individual countries.

Countries otherwise concerned with civil liberties, such as the US and Sweden, were restrictive in their responses, while France and Germany, usually willing to support the involvement of the state, were much more laissez faire in their response to Aids. Baldwin ascribes those divergences to 19th-century responses to epidemic disease. States behaved in the same way they had in the 19th century, when dealing with cholera, yellow fever, smallpox and syphilis. Responses were due to a "deep historical public health memory".

The historical lens of different public-health traditions, and the changing focus of public health from collective to individualised solutions is a good, although not original, framing. Baldwin's book is valuable in making those connections overall rather than just in relation to one country. The text is based on impressive reading (there are more than 160 pages of notes, although, alas, no bibliography) and he is well read in the German and Scandinavian literature as well as the more usual British and American.

Previous texts with cross-national perspectives were published some while ago (Barbara Misztal and Dabid Moss's cross-national study appeared in 1990) and mostly took a country-by-country approach. This book synthesises across the countries and is particularly useful on issues such as testing and screening and how policies in these areas have differed from one country to another.

Was the public health tradition the only motive force behind country responses? After all, there have been other "pre-histories" clustered round Aids, which helped to determine policy. In the UK, debates in the 1970s over self-sufficiency in blood products and the belief within the blood transfusion service that voluntary donation was best, helped construct the response to Aids. Pre-existing, but unspoken, moves towards harm reduction gained political legitimacy with the arrival of HIV among drug users. The gay response and the stress on human rights built on the gay liberation networks of the 1970s. To be fair, Baldwin does start to engage with these arguments. He surveys the state of gay organisation in the different countries; the role of drug policy and its change (important in Britain, but also in France, which had little tradition of treatment before Aids); public opinion; and relationships between local regional and federal or national action. Responses to Aids, in other words, were dependent on the previous traditions of civil society and of the institutions of the state - a somewhat broader argument than the "historical public health memory"

one.

The book is clearly a child of its parent, Baldwin's earlier text, which dealt with European countries. We learn about individual countries, but we do not hear about interactions between countries nor about the role of internationalism in policy transfer. The connection between developing and developed was an important part of the Aids story from the start.

Baldwin does not consider the interdependence within the public health tradition of what we now call developing countries with the developed world, nor the continuing role both of international agencies and of countries such as the US in the dissemination of particular varieties of response - for example, the American ABC (Abstain, be faithful, wear a condom) policy message. The role of international organisations such as the World Health Organisation was significant in the dissemination of Western models of policy and Aids programmes in African countries early on. There is an historical public health tradition here; remember the part played by international sanitary conferences that disseminated public health norms and science internationally; and the public health laws that mother countries applied in their colonies. That past has remained important as Aids in the developing world has assumed growing significance.

The book's focus is the industrialised countries, so the role of non-industrialised states that have adopted more punitive public health models is largely passed over. Cuba, which used extensive screening, sanatoria for the HIV positive and termination of pregnancy for positive mothers, is briefly mentioned. Some commentators have argued that such policies have had greater protective effect and worked better in protecting women and the poor.

Baldwin rightly links Aids and its impact with a revival of public health at the end of the 20th century. As an American, he sees this "new public health" as leading into the subsequent response to terrorism and its threat of disseminating epidemic disease. Aids revived and rejuvenated public health in the UK and other industrialised countries. But that lineage from Aids to terrorism and epidemic disease is not the only inheritance. There are other public health strategies for which Aids was the initial motive force. For example, it gave impetus to the "technical fix" of vaccination and the enhanced role of pharmaceutical companies in providing drug-based preventive strategies for a variety of public health issues.

Public health and its change is a broad canvas: Baldwin has given a valuable survey of at least part of its recent history.

Virginia Berridge is head, Centre for History in Public Health, London School of Hygiene and Tropical Medicine, University of London.

Disease and Democracy: The Industrialized World Faces Aids

Author - Peter Baldwin
Publisher - University of California Press
Pages - 465
Price - £29.95
ISBN - 0 520 24350 1

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