International Journal of Epidemiology 2003;32:891-892
© International Epidemiological Association 2003
Book Review |
Dawning Answers: How the HIV/AIDS Epidemic Has Helped to Strengthen Public Health.
Valdiserri RO. Oxford: Oxford University Press, 2003, pp. 209, £29.95. ISBN: 0-19-514740-5.
Talk about silver linings! Here we have the worst epidemic in centuries, the cause of 25 million deaths and 40 million infections so far. A disease which, striking the young and economically active, is crippling third world economies and halving life expectancies, an epidemic which has lent all-too unfortunate substance to otherwise facile metaphors of the plague’s return. And yet, in this grim cloud, we are to believe, something shiny and good can be found. Public health, the contributors to this volume claim, has learnt lessons from AIDS and has improved. That something positive could emerge from the epidemic is certainly an audacious and counter-intuitive claim.
Whether this sense of public health whiggery can be sustained depends on what exactly is meant. It would be disheartening had public health authorities learnt little from the epidemic and changed less. But, if the epidemic revealed weaknesses in, say, the US health care system, would that count as progress or as highlighting lack of same? Some of the chapters (that by Levi on funding for example) are resolutely downbeat, with little hint of any dawning answers. Nonetheless, there are certainly examples here of how public health has improved. Victims of the epidemic and their interests are now taken much more into account than earlier by those responsible for their well-being. The contagiously ill are regarded as handicapped and entitled to many of the protections that follow. The ethics of double-blind tests of new treatments have been challenged and the rights of the desperately ill staked to whatever medical intervention seems promising. Techniques of evaluating the effectiveness of public health interventions have improved.
In a more general sense, public health has learned to deal differently with contagious disease epidemics than it used to. The legislation in force when the epidemic hit had been formulated largely in the 19th century and foresaw drastic incursions of the stricken individual’s liberty: testing, reporting, isolation, and the like. The new disease could not, so public health slowly learned, be treated in the same way. Its nature did not lend itself to this sort of management. It was spread primarily in deliberate acts of illicit and irregular sexual and drug-taking behaviour, far from the state’s ken. It had a long incubation period during which carriers could easily be unaware of their infectiousness. There was, as yet, no cure and even, for long, not much treatment. Hence the traditional public health measures threatened to be counterproductive, driving already stigmatized and marginal groups even further into the epidemiological underground. Moreover, the civil rights revolution of the postwar period meant that individual liberties could no longer be violated as cavalierly as earlier. Out of such factors came the seachange in public health tactics now developed for the AIDS epidemic—from what has elsewhere been called the contain-and-control strategy to one of inclusion-and-co-operation.
While there is no doubt about such improvements, the overall whiggery implicit in the book’s framing of the issues can be questioned. Not all nations applied the new consensual approach of public health to the epidemic. Sweden and parts of Germany, for example, were happy to use quite traditional approaches. Moreover, the tactics adopted in the US, which are the primary topic here, were much less consensual than they are often interpreted. Testing, reporting, even isolation of the infected were techniques in more common use in the US than in any western European nation, outside of Sweden, Bavaria, and Austria. Add to that, the revival of traditional techniques, discussed here too, that came about starting in the mid-1990s as effective treatments were finally developed, and the picture of any lasting seachange in public health begins to fade. The sudden acute respiratory syndrome (SARS) epidemic, and tuberculosis, and the traditional instruments employed there should also caution against assumptions of an overall change in approach to epidemics. Instead, such considerations should reprompt discussion of how much of an exception was made for AIDS for a certain period of its trajectory in a certain part of the developed world.
The book also touches on, but does not develop very far (the exception being the chapter by Burris and Gostin (one of the best), along with a fascinating chapter by Ronald Bayer on ethics) the inherent contradictions in some of the developments it otherwise praises. Grassroots input, for example, was not always an unmitigated good. Controversies over whether to let seropositive children attend school, whether to let infected medical personnel continue to practice, or whether gay bathhouses should be closed brought out lots of popular opinion on all sides, but it was not always a pleasant, or even good, thing to ventilate it. While emphasizing civil rights was also good, it too was not without its problems. Whose rights was one question? That of the infected victim or the still healthy partner, in issues of medical confidentiality? That of the mother or the soon-to-be-born child, in testing so as to administer AZT? Community involvement did not always ‘push forward’ prevention, as the editor claims (p. 62), but sometimes also backwards.
At the broadest level, the book argues that AIDS brought about a conceptual linkage between human rights and health. Health can no longer, it is claimed, be understood as independent of its environmental, legal, and political context. That there is something to this claim is clear. The movement to override market principles in pricing of new medicines in the third world certainly bespeaks a broader solidarity than was earlier the case. At the same time, it is not the case that people cannot be healthy without democracy and community empowerment. Cuba has staked much of its GNP and prestige in the third world on proving the opposite. Nor is the assertion of such a linkage new. Social medicine, in its broadest formulations, going back at least to Chadwick, Villermé, and Virchow made claims at least as grand and broad. That orthodox public health has now had to relearn the postulates of social medicine bespeaks the interlude of biomedical omnipotence of the last century.
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