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Disease and Democracy: The Industrialized World Faces AIDS

Copyright Date: 2005
Edition: 1
Pages: 478
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  • Book Info
    Disease and Democracy
    Book Description:

    Disease and Democracyis the first comparative analysis of how Western democratic nations have coped with AIDS. Peter Baldwin's exploration of divergent approaches to the epidemic in the United States and several European nations is a springboard for a wide-ranging and sophisticated historical analysis of public health practices and policies. In addition to his comprehensive presentation of information on approaches to AIDS, Baldwin's authoritative book provides a new perspective on our most enduring political dilemma: how to reconcile individual liberty with the safety of the community. Baldwin finds that Western democratic nations have adopted much more varied approaches to AIDS than is commonly recognized. He situates the range of responses to AIDS within the span of past attempts to control contagious disease and discovers the crucial role that history has played in developing these various approaches. Baldwin finds that the various tactics adopted to fight AIDS have sprung largely from those adopted against the classic epidemic diseases of the nineteenth century-especially cholera-and that they reflect the long institutional memories embodied in public health institutions.

    eISBN: 978-0-520-94079-6
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Foreword
    (pp. ix-x)
    Daniel M. Fox and Samuel L. Milbank

    The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. Since 1905 the Fund has worked to improve and maintain health by encouraging persons who make and implement health policy to use the best available evidence. The Fund makes available the results of its work in meetings with decision makers and publishes reports, books, and theMilbank Quarterly, a multidisciplinary journal of population health and health policy.

    This is the thirteenth of the California/Milbank Books on Health and the Public. The publishing partnership between the Fund...

  4. Acknowledgments
    (pp. xi-xi)
  5. Abbreviations
    (pp. xii-xii)
  6. Introduction: Slaves to the Past
    (pp. 1-6)

    This is a book about the influence of the past on the present. Its central arguments are three. First, faced with the acquired immunodeficiency syndrome (AIDS) epidemic, the developed nations adopted surprisingly different approaches to a public health problem that confronted them all with similar challenges. Second, some of these industrialized liberal democracies were markedly more interventionist than others, favoring the commonweal over the rights of infected and at-risk citizens. Which nations subordinated individual liberties to the collective good, and which instead employed voluntary and consensual tactics, was sometimes surprising. Restrictive polities were often otherwise concerned with civil liberties: the...

  7. 1. Bodily Fluids and Citizenship
    (pp. 7-40)

    Whatever else you may think of him, General Jack D. Ripper, Doctor Strangelove’s nemesis, had a point: democracy requires uncorrupted bodily fluids, whether precious or merely quotidian. Blood, sweat, and tears were, in Churchill’s rhetoric, what stood between democracy and totalitarianism. Whether fluoride in the drinking water will help us flash our brightest or a nefarious conspiracy of health communists has set out to administer chemicals unbeknownst to the citizenry, ruining the branch water for our bourbon in the process, is a matter on which even those of goodwill can disagree. But bodily fluids are the sap of the body...

  8. 2. What Came First
    (pp. 41-50)

    At the dawn of the AIDS era, in the early 1980s, public health’s traditional, quarantinist approach to contagious disease was widely thought to have outlived its time. Growing irrelevant in the era of chronic disease, it remained on the books only as a reminder of a bygone age. But then came AIDS and a resurgence of the classic enemies, such as cholera, tuberculosis, and even the plague, as well as new outbreaks of horrifyingly transmissible emergent diseases. The inherited laws and regulations on contagious disease had not been modified for many decades. In principle, therefore, the classic techniques of testing,...

  9. 3. Fighting the Previous War: Traditional Public Health Strategies and AIDS
    (pp. 51-85)

    The first question was whether to treat AIDS as just another contagious disease and its victims as subject to traditional precautions. The second, broader question was whether the venerable quarantinist strategies of prevention could and should be applied. Should screening (possibly of the entire population, perhaps only of certain high-risk groups) to identify seropositives be undertaken? When identified, should the ill or even the infected have their sexual and intravenous drug contacts traced, and could these be warned? Should the infected, in turn, be required to undergo what treatment was available? Should they be obliged to follow behavioral prescriptions to...

  10. 4. Patients into Prisoners: Responsibility, Crime, and Health
    (pp. 86-98)

    AIDS is a disease that was spread, at first in the developed world, mainly by conscious, though rarely intentional, behavior. Questions of individual responsibility and liability, both moral and legal, were vital. The infected often transmitted disease by actions they could have avoided. How could they be discouraged before the fact? How could they be punished afterward? Criminal and civil law, not just public health, were seen as part of the solution in all developed nations. The penal and civil codes were used to control transmissive behaviors and to hold transgressors liable. Indeed, in certain respects, the criminal law helped...

  11. 5. Discrimination and Its Discontents: Protecting the Victims
    (pp. 99-124)

    Throughout the industrialized world, the law was used to discourage and punish risky behavior. Typically, it both outlawed potentially transmissive conduct and increased sentences for acts aggravated by the threat of infection: rape, child abuse, and assault, especially on police or medical personnel. But in other cases, the interaction of the law and HIV meant attempts at mercy and moderation. Compassionate release of prisoners was one example. Should an incurable and lethal ailment be considered when sentencing or paroling inmates or setting them free? In Poland, prisoners deliberately infected themselves in hopes of having their terms reduced. Courts, in turn,...

  12. 6. Every Man His Own Quarantine Officer: The Voluntary Approach
    (pp. 125-152)

    At first, many observers assumed that inherited public health policies could be used without friction against AIDS. Events proved otherwise. AIDS threw a fistful of wrenches into the works of traditional contagious disease control. Caused by a new, scarcely understood, and extremely protean class of infectious agents—retroviruses—it was a disease whose nature resisted treatment and cure. There was little hope of a technical fix, and none for a quick one. On the other hand, the extraordinarily rapid development of knowledge about the disease allowed interventions more precisely targeted at risk behaviors and risk groups than had been possible...

  13. 7. The Polymorphous Politics of Prevention
    (pp. 153-164)

    The developed nations took more divergent approaches to the AIDS epidemic than might have been expected, given the broad similarity of the problem in each and the globalization of scientific and epidemiological knowledge. The British reacted early and effectively, the state taking a leading role and following historical precedents that pointed it in a consensual and voluntaristic direction. A massive public education campaign began in 1986, and a Cabinet committee was established, one that included everyone concerned short of the prime minister herself. A parliamentary select committee and an AIDS unit in the Department of Health were set up; extra...

  14. 8. To Die Laughing: Gays and Other Interest Groups
    (pp. 165-201)

    For diseases, the interest group most concerned should—in theory—be easy to identify. In large measure, it is created by the affliction. The (potentially) ill have obvious interests in research, in treatment, and in compensation for damages. And, in fact, political mobilization on this basis takes place. This explains, for example, why breast cancer has gone from being underresearched to receiving a generous share of resources—but not perhaps why it has taken longer for prostate cancer. It accounts for why a problem like Lyme disease, afflicting suburban commuters, receives attention, while the all-too-common and preventable diseases that kill...

  15. 9. Vox Populi Suprema Lex Est: Expertise, Authority, and Democracy
    (pp. 202-226)

    Public opinion influenced responses to the epidemic. Yet opinion’s effect was in turn shaped by the nature of the state. How permeable to grassroots fears was it? How able to resist easy but vindictive solutions at the expense of vulnerable minorities?

    Faced with past epidemic, the public had—not surprisingly—been fearful and anxious. It often clamored for the authorities to take decisive, even harsh, actions, and was willing to blame scapegoats: Jews during the plague of the Middle Ages; Germans in Philadelphia for yellow fever in the 1790s; the poor, Jesuits, and physicians for cholera in the 1830s; the...

  16. 10. Clio Intervenes: The Effect of the Past on Public Health
    (pp. 227-243)

    The nations under the glass here approached an epidemiologically similar problem in quite different ways, and did so for many different reasons. Yet the multiple causal roots of policy divergence must not obscure this book’s central observation: national public health strategies adopted during the AIDS era were remarkably similar to those that had governed contagious disease for at least the last century. Like generals fighting the previous war, surgeons general and their counterparts wheeled out the inherited preventive artillery when faced with a new disease. Even the novelties introduced to account for the unusual characteristics of the AIDS epidemic could...

  17. 11. Liberty, Authority, and the State in the AIDS Era
    (pp. 244-290)

    In the age of globalization, HIV is among the most cosmopolitan of life-forms, at home the world over. Despite attempts by even the most isolated of polities to exclude it, it has wrought devastation with grim uniformity everywhere. And yet this ecumenical aggressor has been met and dealt with very differently across the world. Why?

    To understand why different nations, even ones with similar cultures and political systems, have pursued various strategies against the epidemic,we need to appraise many factors: the balance of political forces within each nation, the importance attached to privacy, approaches to sexuality, the relative commitment to...

  18. Notes
    (pp. 291-448)
  19. Index
    (pp. 449-465)
  20. Back Matter
    (pp. 466-466)