Disease and Democracy: The Industrialized World Faces AIDS

  • Peter Baldwin
University of California Press/Milbank Memorial Fund, 2005 465 pp., hardcover, $44.95 ISBN 0520243501 | ISBN: 0-520-24350-1

Since the HIV/AIDS epidemic emerged 25 years ago, few subjects have received as much attention from medical and public health researchers. The complicated social and political responses generated by the epidemic in different countries and communities have also become the focus for an extensive literature in social science and historical research. But few volumes in this large scholarly literature come close to matching the detail and the sophistication of Peter Baldwin's remarkable study, Disease and Democracy: The Industrialized World Faces AIDS. Through a highly nuanced comparative analysis of the ways in which a range of different Western democracies have sought to respond to the epidemic, Baldwin's study provides not only the most extensive record of the ways in which the United States and a number of Western European nations have addressed HIV and AIDS, but also a far-reaching understanding of the different approaches that these countries have developed in relation to the politics of public health and its ongoing tensions between the defense of individual liberties and the need to safeguard the health of communities.

Although the different countries that Baldwin examines share much in common, he finds that their responses to the AIDS epidemic have been marked by major differences. Baldwin situates the response to HIV and AIDS in different industrialized, democratic societies in relation to the longer history of the ways in which these nations have responded to the control of infectious diseases. He shows how the policies adopted in different country settings can, to a large extent, be traced back to the approaches that these countries developed in responding to the epidemic diseases of the nineteenth century—in particular, their responses to the spread of cholera.

Although much of the analysis of the politics of AIDS has emphasized its break with this earlier past—the creation of what has often been described as a kind of 'AIDS exceptionalism'—Baldwin finds, on the contrary, remarkable continuities with the past. On one hand, in some countries (perhaps best exemplified by Sweden), severe restrictions have been placed on the civil rights of those infected with HIV in the name of protecting the broader health and well-being of society. Other countries (Great Britain and The Netherlands, for example) have placed emphasis on more voluntary and consensual approaches in response to health education, information campaigns and behavioral change interventions. And, in what are in many ways the most interesting cases (Germany and the United States), elements of both tendencies can be found, often competing in the arena of policy discussion and debate.

To make sense of how these different approaches have taken shape in different countries, Baldwin explores the ways in which their historical traditions of public health and medicine have intersected with factors such as approaches to sexual diversity and morality, changing patterns of immigration and ethnic diversity, and to social heterogeneity more generally. He offers important new insights into the reasons why different democratic countries have often adopted such radically different approaches to a lethal, new, primarily sexually transmitted disease: why the United States and France, for example, seem to have placed such emphasis on biomedical science and technological fixes (such as the search for a vaccine), whereas other countries, such and Britain or Australia, have prioritized health education in seeking to control the epidemic through more political means.

Ultimately, what is most impressive in this study is Baldwin's refusal to offer simple answers or to sign on to a single interpretation or causal analysis. Instead, readers of Disease and Democracy come to understand that epidemics such as HIV and AIDS are not simply medical events, but complex social processes that reflect underlying political, economic and cultural factors. It is precisely because of this that diverse societies can approach “an epidemiologically similar problem” in the wide range of different ways that have characterized the response to AIDS on the part of different industrialized democratic nations.

Disease and Democracy is not an easy book to read. It is extremely detailed and well documented, with vast references to the academic literature on the issues that it examines. It struggles, as will its readers, with the difficult and often contradictory political, moral and ethical issues that the AIDS epidemic has raised. But it is marked by an erudition that makes it pleasure to read. The global AIDS pandemic is perhaps the first, but certainly not the last, of the newly emerging infectious diseases that have come to be associated with the ever-accelerating processes of globalization. Baldwin's insights into how the world has responded to AIDS may well have important consequences for a range of other public health challenges that we will have to face in the near future. As the primary impact of the AIDS pandemic has now moved so substantially from the relatively well-to-do settings that characterize the focus of Baldwin's analysis to the resource-poor countries of the so-called developing world, we can only hope that a fuller understanding of the response to AIDS over the past 25 years in the industrialized world will help us to develop more effective responses to the challenges that the epidemic will almost surely continue to pose over the next quarter-century.