Peter Baldwin, Disease and Democracy: The Industrialized World Faces AIDS.

Peter Baldwin, Disease and Democracy: The Industrialized World Faces AIDS. Berkeley, CA: University of California Press, 2005. $44.95 hardcover.

Peter Baldwin suggests that responses to public health challenges today are largely shaped by past experiences. He illustrates this theory by examining current public health responses to the AIDS pandemic. He poses three major arguments: First, that responses to the AIDS pandemic have been remarkably diverse; second, that industrialized liberal democracies were markedly more interventionist than others favoring communal rather than individual rights; and third, that the intervention approaches chosen broadly correspond to the prevention tactics used during the nineteenth century when dealing with earlier contagious epidemics. The public health spectrum of interventions ranges from those that are considerably restrictive of individual rights in favor of communal protections (such as quarantines, institutionalization, screening, mandatory reporting, contact tracing, and forced treatments) to those that are more laissez-faire and concerned with civil rights and confidentiality (such as found in public health campaigns to change knowledge, attitudes, and behaviors). At one end of the spectrum, impositions of governmental and administrative strictures limit the choices for individuals in the name of protection of the community. At the other end, personal liberty, sexual freedom, and voluntarism characterize interventions.

Control of epidemics may reflect the overall political climate that characterizes the industrial democracies. Also, they are tailored to prior experiences in control of epidemics that may not fit the overall political climate as much as the patterned responses to epidemics. Baldwin argues that the United States and Sweden use more restrictive communitarian approaches while Germany and France use more hands-off approaches. An historical analysis shows the patterns of responding to prior epidemics provides a clearer emphasis than traditional political approaches in the countries analyzed. Historical experiences become better predictors than current political climates. AIDS thus interacts with communal versus individual rights contagion control rather than transcends the metaphors for sexual expression, substance use, race, gender and class. Responding to contagious outbreaks becomes an "epidemiological Rorschach" for complex and intertwined political, social, legal, and moral imperatives.

The "golden age of public health" evinces conflict between ideologies supporting notions of improved health and well-being resulting from improved community development (such as clean air; clean water; sanitation and nutritional adequacy) and those believing improved lifespan is accounted for by advances in medical technology and medical services. Ideology shapes the change focus: from promotion of health and well-being to treatment of pathologies. The political and social climate moderates restrictiveness. For example, public sentiments against quarantines limit the restrictiveness, though the ideological impulses support it.

Professional health care providers may support communal approaches that run counter to their quarentinist, disease prevention or social reformist, health promotion ideology counter-currents. Are epidemics the result of social inequality and noxious environments or contagious pathogens? Context and experience shape responses. Responses waiver between concerns with discrimination, marginalization and stigmatization or control of malevolent organisms. The eradication of contagion becomes the metaphor for community development and social equality or that of plagues and containment. Ideology is accused of willingness to sacrifice the common good for civil rights and non-discrimination in a Western individualism prism, or a willingness to sacrifice freedom for curing ills. Permissiveness and indulgence clashes with zealotry and rigid dogmatism: and epidemic control is the symbol rather than the outcome.

Baldwin provides an engaging portrayal of diverse policy responses in the context of social and political vectors. He presents a wide scope of ideas shaping the policy options but is not indifferent to the restrictive choices favored. While rich in description of policy options and the social and political issues influencing the debates, the argument lacks empirical grounding. Is there scientific support for restrictive versus behavioral change models? There is a detailed story of policy choice outlined in this readable and fascinating text, but not an empirical guide to the impact of these policy choices on pandemic control. The ideological conflict grows in intensity. Some are accused of endangering the public; some are willing to impose draconian restrictions on behaviors in the name of obsequious morality. The question of whether either has a measurable impact on contagion control is illusive, even when the conflict over policy approaches are well documented. Promoting public health is not a fusty theoretical debate, but a drama played out in prisons, in hospitals, in morgues, as well as in legislative halls and in houses of worship. Community development battles pathogenesis for ideological predominance. Contagion is the wager.

Ronald J. Mancoske

Southern University at New Orleans