Disease and Democracy: The Industrialized World Faces AIDS. Peter Baldwin. Berkeley: University of California Press, 2005.
Although seemingly a historical account of European and American public policies against AIDS, Peter Baldwin’s Disease and Democracy is that but much more: it probes into the nature of public policy and political action, with its actors of interest groups, public opinion, and governmental agencies; it raises questions of political theory with the dilemma of how to reconcile individual liberty with communal safety as well as explore the roles of citizenship and responsibility in a liberal democracy; and it offers a synthetic and historical analysis of the vast literature on AIDS in the context of comparative public policy.
By looking at each country’s domestic traditions of public health policy, Baldwin examines how these differences account for the divergent responses towards AIDS among the industrialized countries of Europe and the United States. Against the rational choice theorists, Baldwin sides with the path dependency social scientists who claim that initial decisions are more important than later ones, because the past narrows future possibilities and increases the costs of subsequent changes.
For Baldwin, path dependence continues to structure public health policy, providing an explanation why, when confronted with the same epidemic, some countries favored a more state interventionist approach to AIDS, while others opted for voluntary, consensual tactics. When compared to other epidemics, AIDS seems exceptional in that techniques of voluntary behavioral change instead of quarantines and sanitation were developed for this chronic disease. However, a closer examination reveals that western countries’ initial response to AIDS was similar to their nineteenth-century responses to smallpox, cholera, and syphilis.
Surprisingly, countries that traditionally concerned themselves with the protection of civil liberties, such as the United States and Sweden, implemented interventionist policies, while countries that customarily have subordinated individual rights to the state, like France and Germany, adopted a much more laissez-faire approach. But as the United States, Sweden, Bavaria, and to a lesser extent Austria, continued in their traditional approach of mandatory testing and reporting, contact tracing, and protection of the borders, these countries eventually recognized the ineffectiveness of these techniques and abandoned them for the consensual tactics of educating the public to avoid risky behavior and transmission. The universal mobility of modern life, the dormant nature of the virus, and the ethical and legal questions of discrimination all had made traditional state interventionist techniques such as compulsory quarantines impractical and expensive.
To account for the variation in countries’ responses against AIDS, Baldwin looks at the structures already established in those countries: existing health, marital, and discrimination legislation; employment practices and protection; the treatment of prisoners and prostitution; the nature and extent of health insurance coverage; and public attitudes and governmental agencies. Furthermore, which populace was most afflicted with AIDS – whether it was gays, drug-users, prostitutes, or hemophiliacs; the white middle-class or ethnic and racial minorities – and their sexual practices also played a role in determining public health policy.
Finally, prompted by the bacteriological revolution in biomedicine, the civil rights movement, and the sexual revolution, public health as a whole shifted from quarantine and sanitation to an individualized, democratized approach, whereas individual were responsible for their own safety by their sexual and recreational choices. Instead of employing collective, behavioral control, the state’s role was one of education to persuade the public to change its behavior; or, as Foucault has pointed out, to shift external controls to internal ones. In spite of the problems inherent in this strategy – Should school children be taught to use condoms? Should needle exchange programs be implemented? – this voluntary, consensual approach ultimately came to dominate western countries’ public health policy towards AIDS.
In addition to past public policies and the demographic, geographic, and political structures of a country (what Baldwin terms geoepidemiological factors), the book also looks at the roles and relationships among interest groups, the medical community, and the state in the formulation of public health policy. In all countries, the epidemic’s victims, especially gays, formally participated in policy decisions, although the nature and extent varied according to each country’s geoepidemiological and political structures. Public opinion was diverted by politicians and medical experts into legislative committees and bureaucratic agencies so as to insulate public health policy from populist forces. And the state played its role in public policy decisions with a great variation among countries, depending whether the state was unitary or federal, the roles of court and litigation, and the relationships among the welfare state, employment practices, and civic organizations. But in spite of the vast differences among interest groups, public pressure, and political choices in these countries, all of them, except non-Bavarian Germany, resorted to the strategies and tactics that they had employed in their previous encounters with past epidemics.
Ultimately this diversity of responses to the same epidemic in countries with similar cultures and political systems can be traced to the unique nature of the epidemic, a country’s geoepidemoiological structures, and the politics of public health, biotechnology, and privacy. Here we have the controversies of confidentiality, civil rights and liberties, and communal safety, all of which Baldwin explores throughout his book with precision and objectivity. But the crucial dilemmas raised by AIDS is whether liberal democracies can provide collective goods for its citizens, who now see themselves more as individuals rather than citizens; and whether the First World can continue to ignore the Third World plight without harm to itself.
These questions, and others, are more explored than answered, but highlights the unique nature of AIDS and the obstacles politicians, medical experts, and the public must confront in their formulation of public policy against this epidemic. With the explosion of new discoveries in biomedical research, along with the outbreak of pan-epidemics like SARS, these questions will not lose their political currency any time soon. As the first comparative analysis of western public health policy on AIDS, Disease and Democracy shows how these countries have confronted past and current epidemics with success and failure in public policy and raises the right political questions we need to ask and to address so as to help guide us in the future.
This was originally published with the same title in The Review of Politics 67 (2005): 150-52.