876 Book Reviews

1982. Grmek includes a discussion on viruses that is accessi- ble to readers with nonmedical backgrounds. and summar- izes the history of the discovery of human retroviruses. He describes the work carried out by Robert Gallo and Luc Montaignier prior to the discovery of HIV, and traces the Gallo-Montaignierdisputesurrounding the isolation ofHIV. This section concludes with a description of how the develop- ment of HIV-antibody tests introduced a new dimension to the AIDS epidemic, with the recognition that large numbers of seropositive but overtly healthy individuals were present throughout the world.

In the third and fourth sections Grmek uses techniques of medical history to address the question, “Is AIDS a new disease?” First he examines the American. European and African medical literature for cases that meet the CDC diagnostic criteria for AIDS, and reviews results of HIV-anti- body testing of frozen blood samples collected prior to 1980. He then examines the origin and spread of the causative agents of AIDS, HIV-l and HIV-2. tracing their genealogy and evolution. examining different hypotheses that have been advanced about the origin of HIV, and discussing possible scenarios for the worldwide spread of AIDS. The evidence suggests that HIV may have been present in human popu- lations since the middle of the 20th century but that its presence was masked by other infectious diseases and so the

sporadic cases of AIDS that occurred were not recognized as a distinct clinical syndrome. For the AIDS epidemic to take hold the way it did, certain biological and social conditions had to be met, including the mingling of peoples from diverse geographic areas, the liberalization of sexual and social mores, and the control or eradication of infectious diseases that had previously been endemic in most parts of the world (e.g. smallpox, which was eradicated in 1977). These con- ditions were met in the late 1970s in the gay community in the U.S. and in equatorial Africa where armed conflicts caused social upheaval and dislocation of the population. It is not coincidental, Grmek concludes, that these were two early foci of the AIDS epidemic.

This interesting and well-written book provides a comprehensive summary of the first decade of the AIDS pandemic and presents a thought-provoking analysis of the origins of HIV. It will be of interest not only to readers who work in the field of AIDS research or treatment but also to those concerned with broader questions of medical history and the delicate balance between humans and their physical environment.

MARCELA RAFFAELLI

Near Brunsu’ick, NJ 08903, U.S.A.

Going Private: Why People Pay for their Health Care, by MICHAEL CALNAN, SARAH CANT and JONATHAN GABE. Open University Press. 1993. 113 pp. $10.99

This short book is currently one of seven in a series dealing with the ‘State of Health’ in recent times. Its particular concern is with people’s motives for joining private health insurance schemes and their subsequent use of these services. This theme is explored exclusively within the British context where private subscribers must also contribute payments to the funding of the National Health Service (NHS). The findings are drawn from an Economic and Social Research Council funded project which surveyed subscribers in affluent S.E. England during the late 1980s.

The introductory chapter charts the growth of private health care from the inception of the NHS to the present, when approximately one in seven of the population have some kind of personal cover. This change is explained both by the Conservative Government’s ideological commitment to private initiatives and by the extended choice of care such schemes offer to their clients. Chapter 2 presents a series of socioeconomic profiles of typical private subscribers drawn from the authors’ postal survey of 1688 high income males identified from the lists of four General Practitoners in Kent. The bulk of the analysis is then centered around in-depth (qualitative) interviews with 60 of the original sample, who are stratified according to whether they chose private subscription personally, were co-opted into employer run schemes, or had decided not to subscribe. The opinions, anecdotes and musings offered by these respon- dents provide the materials for chapters on their motives for ‘going private’, which includes their views on opting-out of the NHS, the use they make of private insurance, and their ideological commitment to the delivery of health and wel- fare. The conclusion sets these findings, especially the ambivalence of many respondents with regard to the need for both private and public provision, within the context of recent sociological and political debates.

The stated aim of this series (p. vii) is to go beyond the usual textbook format by providing works which stimulate debates that will be informative to students, health re- searchers and policy-makers. To this end, ‘Going Private’ works well: the text is direct and concise; the extensive use of quotations and tabular information helps to illustrate the agenda; and, a refreshingly neutral tone is achieved because the authors do not allow their opinions to intercede with those of the respondents. Accordingly. this book manages to make a balanced contribution to the loaded political controversies about health service reform.

Despite this positive response, I had a number of reser- vations about their conclusions, which all stemmed from an over-reliance on qualitative research methods. Much is made, for example, of the tendency for most respondents to support the principle of public health care, which is taken as evidence to suggest they would resist political reforms to introduce a fully privatized system. However, my reading of their opinions left me with the distinct impression that these rich men of Kent were. ideologically at least. a slippery bunch. Typical amongst them are impatient liberals, who support the NHS but use private insurance as a useful method of queue jumping, and ardent privateers, who still regard the NHS as an essential cushion for their lack of personal health cover. What unites most of them are their consumerist motives, which suggests their professed support for the NHS might dwindle if they were presented with a sufficiently enticing private health package. Given these ambiguous interpret- ations. 1 thought a more detailed analysis of the economic intentions of the respondents might have been attempted. In particular, I was curious to learn about the types of private incentives that would lead them to substitute personal income for access to public services. Finally, while these arguments imply ‘Going Private’ is somewhat restricted in its scope, they also demonstrate its ability to generate debate.

Uniaersity of Manche.ster Manchester Ml3 9PL England

RICHARD THOMAS