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Peter Baldwin, Contagion and the State in Europe, 1830-1930, Cambridge University Press, Cambridge 1999, xiii + 581 S., brosch., 45,00 £.

"New Public Health", born in the late 1980ies, has meanwhile come of age in so called 'post-industrial' countries. This new approach to health problems shifts from infectious and chronic diseases to the so called "new morbidity": the vast field of behavioural disorders, the even vaster field of psycho-mental disorders including addiction and violence, and finally to chronic diseases mainly of elderly people and of people, who survived severe illness and forced medical intervention. At least there is also a revival of infectious diseases, but also not in epidemic outbreaks, but on a new level of the interaction among new or resistant germs, immune-deficient hosts and the various situations of social and biological vectors (e.g. Hepatitis C; multi-resistant Tuberculosis; nosocomial infections etc.). Beneath that surface some people are even forecasting the consequences of the molecular transition of medicine in the field of public needs and public interventions: so "public health genetics" are a rising topic for education and advice in a forthcoming molecularised world.

The revival of public health also gives new momentum to a historical analysis of this unique feature of medical intervention, which, as we all know, is the main source for preserving life and health on a large scale. Following new orientations and approaches in the historiography of medicine, new publications focus also on new subjects, using new methods and new sources. Thus a new history of public health deals with the construction of special public notions of health, the social negotiations of different public interventions ("contagionism" vs. "localism"), the reactions of client-groups as a sort of a history of a public patient (e.g.: reaction on small-pox-inoculation). Most interesting are those studies trying to contribute to public health problems of today by well chosen historical examples and adequate historiographic methods. This is e.g. especially effective in the history of malaria, e.g. in the revival of "naturalistic measures". So combining at least some of these new questions on the level of an international comparison would probably offer an exciting insight into the complex machinery of public health. But who is going to develop a comparative concept, dealing with these issues over space and time, mastering the masses of material and getting it all together in a readable book?

Did Peter Baldwin, Professor of Modern Europe at the History Department of the University of California, Los Angeles, master at least some of these problems in his impressive book on "Contagion and the State in Europe, 1830-1930"? In the first chapter on "Preventive variations" (pp.1-36) Baldwin opens a vast horizon what has to be considered when writing on public health: first the epistemology of epidemics from ancient times until the 19th century; secondly the politics of public health, always invoking the dilemma in the contradiction between individual rights and the demands of the society under the heading of individual and public health; thirdly the etiological dualities between political ideology and preventive tactics, raised by Erwin H. Ackerknecht in his famous paper on contagionism. On the top of the worldwide discussion on the subject - post-Ackerknecht and post-McKeown, post-Foucault and post-Elias, and all the other approaches to this intriguing field of research - Baldwin defines his starting point: prophylaxis as a continuation of politics, the general question, that public health measures inevitably carry public interests and political implications. This theory is to be examined on the example of Germany, Sweden, Britain and France to the successive problems of Cholera, Smallpox, and Syphilis during the nineteenth century.

The chapters "Enter cholera" (pp. 37-122) and "Cholera comes of age" (pp. 123-243) are dealing with the most scandalised acute epidemic infectious disease of the 19th century. "Smallpox faces the lancet" (pp. 244-354) concentrates on an acute endemic infectious disease well known in Europe. "Syphilis between prostitution and promiscuity" (pp. 355-523) deals with a disease, that is not connected with a general threat of the public, but mainly with personal behaviour and social norms. So Baldwin looks for a series of diseases, which were "scandalised" focuses of public-health-developments. In this series obviously typhoid and tuberculosis are missing: acute epidemic infectious diseases like plague, small-pox, or cholera, acute endemic infectious diseases like typhus, typhoid, or diphtheria, chronic endemic infectious diseases like tuberculosis, and finally sexually transmitted infectious diseases form a chain of public health interventions, which led to the thoroughly hygienised, bacteriologised, pasteurised western societies of today.

In the final chapter "The politics of prevention" (pp. 524-563) Baldwin draws the conclusion of his comparison. And confronted by the masses of material and the complexity of the questions, these conclusions seem quite simple. In looking for an "Archimedian Point" to compare public health interventions on an international level (p. 524) Baldwin finally ends up with a sort of a geo-epidemiological theory: the more distant the country to the origin of the epidemic threat, the more accumulates experience in dealing with the problem; in the (international) process of the epidemic a sort of an implicit manual of possible interventions is emerging, finally to be in parts implemented due to space and time in different regions. Though geo-epidemiology is by no means simple in its historical contexts (e.g.: Nazi-medicine in the USSR - see Paul Weindling’s recent masterpiece "Epidemics and Genocide in Eastern Europe"; e.g.: "roll-back-malaria" the sub-Saharan Africa) they hardly may serve as a general approach of the intricate problems of public interventions in health. And this is probably one of the reasons, why endemic infectious diseases such as typhus or typhoid are missing in Baldwin’s survey. And, by the way, though giving an exhaustive Index (pp. 564-581), a bibliography of the vast literature is missing and - alas - thus restricting the every-day-use of this publication as an acclaimed textbook for beginners.

So in the end, what is the outcome of this gigantic enterprise - which this volume obviously constitutes. Did Baldwin meet his explicit and implicit aims: do we find that comparative approach of Archimedian quality? Do we find a useful book to be recommended as well for historians as for activists in the public health scene? The questions BALDWIN raised as guidelines for his historical investigation are by no ways new. Especially in the field of a historical sociology of public health they are dealt with since many years. Interventions in public health can only be public, so they are based on politics and the interaction among politicians and scientists, administrators and doctors etc. But even this basic law of any public intervention in health is not adequately observed neither in the history nor in the practice of public health as well. But Baldwin’s book does more than dealing with an old but somehow hidden question again. His is one of the very few works in international comparison accomplished not in 'hard data', but on the level of conceptualising diseases and interventions, based on an impressive use (knowledge?) of the national and international literature on the subject, readable and with lots of insights and fruitful ideas for further research in every chapter. So everyone will agree, that Baldwin’s "Contagion and the State" may serve as an acclaimed introduction to the field: any student, any young scholar, who wants to join history of public health, should go through this book. And there is another strong point: compared to the hermetic, if not autistic discussion of the topic among Anglo-American scientists, who hardly notice any question nor any research nor any results except those referring to Great Britain or the US and being published in English, Baldwin is one of the very few, who at least tried to get into the European question. Just this would justify best recommendations on the continent. So keep Baldwin’s book and his ideas in discussion to enhance a real international debate on the as well exciting as fruitful questions about the intriguing machinery of public health.

Alfons Labisch, Düsseldorf


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