430 Book Reviews

understanding of disease and health care in developing countries, the need is for an analytic framework which integrates an ‘ecological’ with a ‘political economy’ ap- proach.

Department of Geography Queen’s University Kingston, Ontario, Canada

CHARLES &YINAM

No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880, by A. M. BRASDT. Oxford Univer- sity Press, New York, 1985. 245 pp. 519.85

In its preface and introduction this book promises to cover a time period from the late nineteenth century to “the current epidemics of herpes and Acquired- Immune Deficiency Syndrome (AIDS)” and to adont a oosition which emphasies the ‘social construction’ oi venereal dis- ease, but neither pledge is fully redeemed. Perhaps it was unfortunate to make such claims because without them the book is a very readable and interesting account, seemingly carefully researched, of venereal disease and the public response it elicited earlier this century.

The enticement of a social history of herpes and AIDS- reproduced on the dust cover-is not well supported. As history the book is weakest in covering the period after the Second World War and the analysis of the current epidemics of herpes and AIDS amounts to barely half a dozen pages. Yet the book’s strength lies in providing an essential back- drop against which analyses of the new epidemics must take place. The earlier part of the century in America is well covered and provides a fascinating account of the constant struggle of social reformers and moralists with a disease which both marked and was spread by illicit sexual encoun- ters.

The introductory chapter however seems to promise even more for a social scientist as Brandt directs attention to the issue of the ‘social construction’ of venereal disease, in other words to ‘social definitions of venereal disease.’ There is a growing literature within medical anthropology and sociol- ogy which takes disease categories as fundamentally social in origin. In this sense venereal disease itself-and its causes, manifestations, consequences, rates, extent, etc.,-are in some way bound up with the society which recognises them. But Brandt travels only part of the social construction road and this is the book’s key failing.

The ‘social construction’ of venereal disease for Brandt means two things. First, there is a thing out there called venereal disease which Wassermann and Ehrlich saw in their test-tubes. Second, there is the social and symbolic baggage which such germs attract. Brandt’s variety of social history is to emphasise the importance of the latter and to minimise, though clearly acknowledge, the former. This approach has its merits and escapes the hagiography often associated with medical histories of discovery, progress and cure. But the failure to treat the presence of the microbe, and hence the disease, in a socially critical way ultimately mars the book from the viewpoint of a social scientist.

In part the book is about venereal disease as a ‘social problem’, of how campaigners and moralists made it into a ‘problem.’ But Brandt seems to believe that in addition it was somehow a ‘problem’ in its own right, particularly in terms of its epidemic proportions. At certain times he reports other’s views, but elsewhere he clearly speaks for himself. Thus, for example, he points out that despite failure to treat venereal disease in the 1920s “the staggering dimen- sions of the problem had nonetheless been clarified” @. 129); even with gains in knowledge in the inter-war years “syphilis and gonorrhea fluorished” (p. 131); that the “reservoir of untreated and inadequately treated infections thus grew, generating a national health problem of immense proportions” (p. 133); and so on. But how does Brandt ‘know’ that venereal disease was such a problem? Does he

believe that his historical sources represent more than an account of the symbolic domain? Surely, he seems to be saying, with all this hullabaloo and even ‘scientific’ reports of an epidemic, something ‘real’ must have been happening out there. But was there?

Was there ever a venereal disease epidemic at any time this century? At an epidemiological level there are certainty grounds for scepticism; indeed Brandt himself seems aware that diagnosis tended to be a haphazard affair, that claims of prevalence often seemed inflated, that diagnostic tests produced false positives and that the incidence was con- stantly in dispute. Moreover, before the post-war advent of the randomised controlled clinical trial there is no epi- demiological basis for evaluating the success of any prophy- lactic or treatment regimes. At another level, whether there really was an epidemic is unanswerable: instead, and more important from the point of view of the social sciences, is the question of the ‘case’ and the ‘rate’ of venereal disease as symbolic events. If Brandt had fully pursued the ‘social construction’ of the epidemic he reports, a different book, more based on moral panic, may have resulted. In this latter, even perceived numbers are unimportant, as can be seen by the AIDS scare which kills a fraction of those killed on the roads. The symbolic world and the microbiological world are not as separable as Brandt assumes.

Unit of Sociology Medical School, Guy’s Hospital London, England

DAVID ARMSTRQSG

Pharmaceuticals Among the Sunrise Industries, edited by NICHOLAS WELLS. Croom & Helm, London, 1935. 240 pp. f19.95. Proceedings of an Office of Health Economics Symposium held at the Royal College of Physicians, London, 22-23 October 1984.

The papers published in this collection are concerned with issues and problems of the ‘sunrise’ industries, focusing on the pharmaceutical industry as an exemplar. The Office of Health Economics was founded in 1962 by the Association of the British Pharmaceutical Industry. Its terms of refer- ence are: to undertake research on the economic aspects of medical care; to investigate other health and social prob- lems; to collect data from other countries and to publish results, data and conclusions relevant to the foregoing. Hardly surprisingly, in the main, the Proceedings reflect an industry perspective, i.e. a view from the inside. Amongst the most notable exceptions to this are the contributions by Professor Sir John Butterfield (Vice-Chancellor of the Uni- versity of Cambridae). Professor Sir Richard Doll and ProfeSsor Tony Cuiyer (University of York). Professor George Teeling Smith (Director of the Office of Health Economics) epitomises the mood of many participants in a paper on ‘Politics and the Present Pattern.’ The quotation from Teeling Smith expresses a widely shared belief amongst speakers:

“a series of organisations purporting to represent the broad public interest have launched a massive and concerted attack on the activities of the pharmaceutical industry throughout the world. These organisations include Oxfam, War on Want, the World Council of Churches and Social Audit, as well as the international umbrella organisation, Health Action International. These are supported by polit- ically motivated doctors and their objectives are mirrored in the health policies of Britains two (!) socialist parties- Labour and the Social Democrats” (p. 72).

The message is clear. All of us who have naively assumed that stricter control and more rigorous price competition within the industry would actually be in the pubhc interest, are simply misinformed. We are, it seems, misguided ‘do-