Disease and Democracy: The Industrialized World Faces AIDS (review)

Today aids is taken for granted in the developing world. It is viewed as just one of many endemic, chronic conditions that cause great pain and loss of life, yet garner little public attention. Twenty-five years ago, however, aids was the plague. A new, deadly, sexually transmitted disease that disproportionately affected gay men and other socially marginalized communities, aids posed myriad challenges to the health care, public health, and legal systems in each of the nations in which it appeared.

In Disease and Democracy, Baldwin examines how five Western nations, the United States, United Kingdom, Germany, France, and Sweden, responded to aids. Looking at each nation's approach to a variety of questions raised by the epidemic, such as the confidentiality of hiv tests, or whether to protect employees with hiv from discrimination, Baldwin demonstrates both the similarities of the debates and the differences in policies ultimately adopted. As Baldwin sees it, certain countries typically viewed as tolerant on matters of individual behavior, such as the United States and Sweden, actually adopted more restrictive and coercive approaches to the disease than did other countries, such as France or Germany (with the exception of the state of Bavaria), often considered less libertarian. Employing path-dependency analysis, Baldwin argues, not altogether persuasively, that the different policies implemented had more to do with the different approaches that each nation adopted in the nineteenth century in response to infectious diseases like cholera than to hiv-specific debates. Old infection-control policies, he contends, placed each nation on a different infectious-disease-control path that helped to determine the policies adopted when hiv arrived.

The strengths of this book are its comparative emphasis and its comprehensiveness. Although the literature on the early years of the epidemic is vast, Baldwin does an enormous service in covering many different facets of hiv policy and shedding light on the debates in smaller nations, such as Sweden, that are often overlooked, at least by U.S. scholars. Moreover, by emphasizing the heritage of prior infectious-disease laws, Baldwin helps to dispel the myth that hiv and the debates that it spurred were unique. As Baldwin makes clear, arguments whether to adopt infectious-disease policies that emphasize the limitation of individual liberty or those that rely more on voluntary approaches pre-date hiv by centuries.

Paradoxically, the very comprehensiveness of Disease and Democracy weakens its persuasiveness. Baldwin does such a good job of showing the muddled and ever-changing nature of aids policy that his thesis about the legacy of infectious-disease laws is not always convincing. For example, because, as Baldwin shows, it is difficult to draw any simple characterizations other than "inconsistent" about the U.S. approach to aids, it is difficult to trace U.S. aids policy to a prior approach (as if there were one). Moreover, as Baldwin demonstrates, each nation came to hiv with a host of other, significant experiences (such as Nazism in the case of Germany) that shaped its choices. To say that infectious-disease policy was the dominant, path-determining variable is too simplistic.

Baldwin has a tendency to raise rhetorical questions implying answers that cannot be sustained. He also resorts frequently to over-generalizations and broad characterizations, many of which are disproved by other passages in the book. Yet, although all the conclusions do not always hold up to close scrutiny, Disease and Democracy brings great insight and learning to its subject.