Les etats face au Sida en Europe (review)

Monika Steffen has produced an interesting survey of the ways in which four European countries—France, the United Kingdom, Germany, and Italy—have responded to the AIDS crisis. While noting that in the scale of suffering these countries have not been strongly touched ("France and Spain, the two countries of the European Union most strongly affected by AIDS, have fewer cases than New York City" [p. 10]), she aims to survey how the European welfare states have dealt with AIDS. Writing from a public-policy perspective, she shows how countries with relatively flexible but well-integrated systems have adapted to the crisis somewhat better than others.

After establishing a Weberian "ideal type" model of responses to AIDS, Steffen notes that Northern European countries have done the best job. Initially, the North American response among gay men was the model used. The Terrence Higgins Trust was active in AIDS work in the United Kingdom, and gay men were politically active in Germany. In France, Foucault's death from AIDS in 1983 galvanized the gay community.

Drugs were more of a taboo than sex, Steffen asserts, and this factor led to a disjunction between public health campaigns and reality. In Italy and in France relatively few people were at risk for sexually transmitted AIDS, but there was a greater willingness to talk about sex than about the more stigmatized problem of drug use. In several cities in the United Kingdom (Liverpool, Manchester), efforts to minimize the risk of infection through contaminated needles worked smoothly with good results, but in cities such as Edinburgh, local opposition and foot dragging led to many deaths. In general, though, Steffen suggests that France and Germany had repressive legislation regarding drug use and AIDS, while Italy and the United Kingdom tried a more liberal approach. Outside the official French response to the drug problem were the actions of the organization Médecins du Monde, which promoted needle exchange.

The AIDS crisis occurred at just the time when therapy for hemophilia was calling for a greater use of blood products. Not surprisingly, the response of the four countries to the problems posed by hemophiliacs' need for repeated transfusions varied. The United Kingdom asked gay men not to donate blood, but Steffen suggests that this was done less as a measure of exclusion than as "a precaution against a precise and serious risk" (p. 156). Italy suffered from great regional variations in terms of the blood supply. Germany was challenged because its physicians called for an especially high usage of blood products. Finally, in France, where donating blood in the workplace was a strong symbol of community solidarity, excluding problematic donors was more difficult. Steffen goes into some detail about the serious French problems in maintaining a clean blood supply.

In a final chapter, Steffen adds an interesting cultural dimension to her argument: Catholic countries have the highest incidence of AIDS, and Protestant countries the lowest; mixed regions are somewhere in the middle. Among the explanations for this fact, "too massive to be ignored" (p. 222), Steffen invokes the more pragmatic relation between church and state characteristic of Protestant countries. Northern countries, mainly Protestant, also are seen as having a better ability to mobilize individual action and organize collective action. Steffen's conclusion pays homage to Weber, but she also shows how a common European AIDS policy is evolving.

This book will be of interest to students of public policy and to people teaching the history of the AIDS crisis who might want to combine it in their courses with some more patient-oriented treatments of AIDS, such as Bernard Paillard's Notes on the Plague Years.¹