Book Review

Disease and Democracy: The Industrialized World Faces AIDS

N Engl J Med 2005; 353:2824December 29, 2005

Article

Disease and Democracy: The Industrialized World Faces AIDS
(California/Milbank Books on Health and the Public. 13.) By Peter Baldwin. 465 pp. Berkeley, University of California Press, 2005. $44.95. ISBN: 0-520-24350-1

As we approach the 25th anniversary of the first reports of the disease that would become known as AIDS, one might wonder what more there is to be written about the responses to the epidemic by Western nations. Much of the territory covered in Peter Baldwin's Disease and Democracy is familiar, having been thoroughly documented in the vast academic and popular literature on the social, political, and cultural ramifications of AIDS. But the book has several strengths — above all, its comparative international perspective — that make it a fresh and enlightening contribution.

Baldwin, a historian who has analyzed the different approaches to illness, medicine, and politics in European countries, seeks to account in his current book for variations among Western nations in public health policymaking. He primarily concentrates on the United States, Britain, France, Germany, and Sweden, with occasional side trips to other European nations and industrialized countries in other regions. He examines each country's policy responses in the context of its legal and constitutional systems, cultural beliefs and practices, demography, and even its physical geography and topography.

Baldwin advances two related arguments. First, he contends that the responses of industrialized nations differed in striking and often counterintuitive ways. All the countries he describes drew on a shared set of public health strategies: coercive interventions such as isolation of infectious patients, mandatory reporting of cases, and criminalization of transmission, and persuasive measures such as health education and promotional campaigns to prevent the spread of HIV and improve the health of those infected. Choosing among these approaches required confronting the perennial ethical and legal questions that arise when governments attempt to balance individual rights and communal well-being. The measures each country adopted, Baldwin shows, did not always map neatly onto its political or civic culture.

Second, he argues that patterns of history weighed heavily on the policy choices that were made and that national responses were influenced by precedents dating, in many instances, to encounters with disease in the 19th century. Baldwin repeatedly invokes the military metaphor of generals fighting the previous war, with each country's public health leaders falling back on approaches tested against earlier contagions, such as smallpox and cholera.

Baldwin takes for granted that his audience has a fair amount of knowledge about the countries under analysis, and it may at times be heavy going for readers not well versed in the varied political and social contexts within which AIDS policymaking took place. The material is organized thematically, with chapters devoted to issues such as legal discrimination, questions of individual responsibility and voluntarism, the influence of patient advocacy groups, and the contested status of scientific authority. This structure is effective for placing divergences in policy into sharp relief but is less effective for presenting a coherent picture of any one country.

Nevertheless, Baldwin has synthesized an impressive amount of material with skill and nuance. He is skeptical toward cant and conventional wisdom; the chapter on identity politics and the effects of activism by interest groups regarding measures to prevent AIDS is especially incisive. Baldwin's lively and sardonic writing style is refreshingly unacademic (though his colorful turns of phrase sometimes cloy). Disease and Democracy illustrates how valuable a historical and cross-national framework can be for understanding the contentious process of public health policymaking.

James Colgrove, Ph.D.
Columbia University, New York, NY 10032
jc988@columbia.edu