Reviews Book

Disease and Democracy: The Industrialised World Faces AIDS

BMJ 2005; 331 doi: (Published 20 October 2005) Cite this as: BMJ 2005;331:970
  1. Jennifer Prah Ruger, assistant professor (jennifer.ruger{at}
  1. Yale University School of Medicine, New Haven, Connecticut, USA

    Historians are calling Hurricane Katrina—which hit the US Gulf coast and the Louisiana city of New Orleans at the end of August—one of the most devastating natural disasters in American history. In its immediate aftermath, the mayor of New Orleans, fearful that prolonged flooding and contaminated water would lead to dehydration, food poisoning, and the spread of hepatitis A, cholera, and typhoid fever, issued a mandatory evacuation order. Those who failed to leave the city voluntarily might be forced to leave. Local, state, and national authorities have since been blamed for failures to respond effectively.

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    Peter Baldwin

    University of California Press, £29.95/$44.95, pp 478 ISBN 0 520 24350 1


    In Katrina's wake, Peter Baldwin's Disease and Democracy strikes a resonant chord. Baldwin analyses differing approaches to the AIDS epidemic among industrialised countries. He argues that the divergence in AIDS strategies in the US, Britain, Sweden, Germany, and France is path dependent—predetermined by earlier 19th century efforts against other epidemic diseases, such as cholera and syphilis. He argues that “traditional political analysis of the response to the epidemic is inadequate. Left and right, conservative and liberal, are not labels that help explain why administrations and nations adopted their approaches to the epidemic. Such decisions were taken in accord with deeper, prepolitical policy structures already set in place during the previous century.”

    In particular, Baldwin emphasises historical societal preferences established in the 19th century on either side of the line dividing consensual, voluntarist strategies (education, counselling, and voluntary behavioural change) from “harsh” public health interventions focused on quarantine, compulsory institutionalisation, and forcible treatment. Thisdivision represents the age old conflict between individual liberties and the collective good.

    Inarguably, the concept of path dependence helps us analyse responses to disease epidemics, natural disasters, and broader health policy developments. A prime example is the United States employer related health insurance system—still intact, despite much criticism, owing partially to a labour-management compromise earlier in the 20th century. History does matter as an enduring influence and helps us understand contemporary policy and practice.

    At the same time, however, no analysis of institutional memories is complete without amore in-depth examination of underlying norms and values embedded in those institutions. The moral templates and values of organisations, interest groups, political parties, and individuals prompt them to take certain positions and advocate key agendas, which in turnshape societal decision making. Baldwin's use of historical institutionalism—his book's primary analytical framework—is helpful in highlighting history's contingencies and the persistence of precedents and path dependency. But while he emphasises a conflict between individual liberty and the collective good, his framework neglects more fundamental norms of justice, fairness, redistribution, and human behaviour.

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    Should we blame politics or history for the public health fiasco after Katrina?


    Understanding a culture's respect for human dignity and agency is essential to any analysis of HIV and AIDS. Analysing responses to HIV/AIDS from the perspective of norms and values over time, for example, would reveal significant intellectual and moral transformation and reform. It would show changes in cultural views of morality, class, race, and inequality. Norms about lifestyles of those initially most vulnerable to HIV transmission—gay men, prostitutes, and injecting drug users—are of particular interest, as are the presence and persistence of health disparities among vulnerable populations.

    A normative framework would help us discover whether responses such as victim blaming are less prevalent now than previously. It would reveal the values that underlie or precipitate a “voluntarist” approach (respect for human agency and autonomy) as opposed to a “harsh public health” approach (centralised social engineering). Analysis of these underlying values might demonstrate that countries' policies and practices fit less neatly into one of these two overarching strategies.

    Such is the case with the American response to Hurricane Katrina, which represents both harsh public health and voluntarist realities (see p 916). Looking more deeply at the Louisiana example, one finds a public health fiasco whose national policy response reflects lack of consensus on many key public health values—equity, efficiency, compassion, altruism, autonomy, security, safety, and choice. Americans' and Louisianans' views on race and class have significantly influenced the region's disaster preparedness. Contrary to Baldwin's analysis, an examination of Katrina does expose political ideology embedded in public policy—in this case conservative public policy toward poor African-Americans. It reveals a built-in bias manifested in disparities in wealth, access to transportation, and overall ability to respond to disaster. This bias represents not only path dependence but more recent shifts towards conservative ideology, for example in housing policy in New Orleans over the past several decades and Bush administration values. The failure to respond effectively is rooted not just in history as much as in current circumstances and administration views of public health, security, poverty, and race.

    Hurricane Katrina has taught us that US government policy can result in the unnecessary loss of hundreds of lives. The American response to this disaster has been an affront to social justice—a failure to respect the human dignity of all people. That it happened in the year 2005 might have something to do with history, but equally likely it tells us about who we are today.