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International Politics

, Volume 53, Issue 3, pp 343–360 | Cite as

Domestic contexts for response to global HIV/AIDS in France: Perception, media role and civil society

  • Young Soo Kim
Original Article

Abstract

France showed incremental increases in foreign aid for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) with the slope being steeper than Japan but being gentler than the United States in the 1980s. The intermediacy in the behavioral pattern was conditioned by domestic social and cultural determinants that constituted the understanding and the view of the impacts and the implications of the epidemic among the public and the policymakers. The newly emerged epidemic was distinctively framed and understood as ‘gay disease’, ‘social phenomenon’ and ‘national cause’. The research traces the process in which such determinants as the number of HIV-infected, role of the media and activism of civil society organizations shaped the perception of HIV/AIDS as something that needed to be publicly discussed and immediately responded at the national level.

Keywords

HIV/AIDS foreign aid policy France perception media civil society 

Introduction

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has been on the international agenda since the first cases reported in the United States (US) in 1981.1 The epidemic is estimated to claim more than 39 million lives and most major donor countries in the Development Assistance Committee (DAC) have been committed to fight against it (UNAIDS, 2014). They converged in the decision to commence global AIDS funding under the overarching social structure of the World Health Organization (WHO). WHO developed and disseminated the idea of urgency and obligation of international cooperation to the pandemic, that is, norms of global response to HIV/AIDS (Kim, 2015a). In other words, the WHO taught major donors the international norms by reminding them of the identity of DAC membership and associated sense of obligation.2

Each country, however, varied in the patterns of the funding development. Some countries, such as the US and Sweden, showed dramatic increases, whereas others, such as Japan, showed an unwillingness to commit financially. Still, others like France and Germany placed themselves in the middle with incremental increases of the aid.3 I claim that the distinctive patterns depends on how the pandemic was domestically framed and understood. Policy commitment is more likely when an internationally shared idea is domestically accepted and internalized. In other words, the domestic resonance of international norms is dependent on the ‘match’ between the norms and the domestic perception.4 The perception, thus, matters as an intervening variable that conditions domestic diffusion of international norms. When it comes to HIV/AIDS, the perception of threats requiring immediate international cooperation determined global funding level of respective donors. When the issue became salient and the public viewed it as a threat and problem requiring immediate responses, the foreign aid increased. Figure 1 shows a varying perception of HIV/AIDS and the level of the funding in the US, France and Japan in 1987. The second chart illustrates the hierarchy of funding (in amounts) of the three countries. The third chart shows the public’s view of AIDS; 68, 39 and 13 per cent of the public of each country chose AIDS when asked ‘What would you say is the most urgent health problem facing this country at present time?’ There is a positive correlation between the size of funding and the public’s view on the epidemic as an urgent health problem. In other words, the higher the threat perception, the more foreign aid was committed.
Figure 1

Global AIDS funding, AIDS cases, view on AIDS and degree of concern of AIDS in 1987.

Source: Mann et al (1992, pp. 520–521), Mann and Tarantola (1996, pp. 381–383), Webb (1988, p. 351).

Herein lies the critical question: Under what conditions do the international norms and domestic understanding match? Some countries easily concurred with the internationally shared view imposed by the WHO, while others hardly accepted it. The ‘match’ was contingent upon the social and cultural conditions of each country, which determined how AIDS was viewed. I argue that certain determinants created necessary conditions for the foreign aid policy establishment, under which the public and the elites became aware and alert of the newly found and widely unknown disease, perceiving it as an imperative issue needing an urgent response. The determinants include the number of HIV-infected people, the attitude and role of the media, and civil society organizations dealing with HIV/AIDS, each of which played significant roles as intervening variables that filtered the internalization of the international norms. The causal mechanism is addressed in Figure 2.
Figure 2

Causal mechanism of foreign aid policy choices for HIV/AIDS.

The study particularly delves into the process in which the determinants constituted the perception change along with foreign aid policy development in France in the 1980s. France commenced global AIDS funding in 1987 under the WHO structure. Its government allocated the first funds to the Global Program on AIDS (GPA) in the WHO, the first supervisory organization exclusively specializing in HIV/AIDS for monitoring its trend and impacts (France, 2002, p. 11). France paved a way in creating the first monitoring system in the GPA’s epidemiological survey in Central Africa to estimate the scale and geographical distribution of the disease. The government, subsequently, launched an emergency program that supplied screening kits to blood banks and transfusion facilities in recipient countries. The program contributed to developing special information, education and communication actions. Following the incipient actions, France made moderate progress in the aid commitment until the early 1990s in comparison with other major donors such as the US or Japan (see Figure 3).
Figure 3

Total US, French and Japanese global AIDS funding, 1986–1993.

Source: Mann et al (1992, pp. 520–521), Mann and Tarantola (1996, pp. 381–383).

I argue that such increasing commitments of French government were related to the development of a certain perceptions of the epidemic. The Ministry of Foreign Affairs declared HIV/AIDS as an urgent global health crisis and regarded the global fight against the epidemic as one of the top priorities of the foreign aid agenda (France, 2002, p. 13). The view of French government was corresponding to the international norms that the WHO and GPA promulgated and disseminated. The internationally shared idea contributed to increasing the French foreign aid for HIV/AIDS. The research, therefore, explores how the view and the attitude toward the epidemics was shaped and framed in the domestic social and cultural contexts in France in the mid-to-late 1980s.

Construction of Threat Perception for the Response to HIV/AIDS

The perception of threats requiring immediate international cooperation determined the level of the global funding of respective donors. The view mattered because HIV/AIDS was not just a medical event, but a complex phenomenon having dimensions of discourse and politics (Caron, 2001). Regardless of how the disease was defined from a medical and scientific point of view, it was the perception or view shared by the whole society that triggered certain concrete actions, either domestically or internationally. As Crimp (1987) asserts, ‘AIDS does not exist apart from the practices that conceptualize it, represent it, and respond to it. We know AIDS only in and through those practices’ (p. 3). Treichler (1987) echoes that ‘[w]e cannot … look “through” language to determine what AIDS “really” is. Rather, we must explore the site where such determination really occurs and intervene at the point where meaning is created in language’ (p. 31). The research focuses on the construction of the reality and the perception regarding HIV/AIDS in France in order to grasp the necessary conditions of distinctive policy development for the global health crisis.

The number of HIV-infected people is a significant determinant, which influenced the view or attitude of the public. The greater the number of people infected with HIV, the more likely it was that the issue reached the public and the elites through various pathways. That is to say, the epidemic became salient as people were frequently exposed to the information. Figure 1 shows the correlation between the size of HIV-infected population and the view of AIDS as threat in the US, France and Japan in 1987; the number of cases was 27 464, 2165 and 34 in the US, France and Japan, respectively, in the first chart. The hierarchy in the numbers matches the percentage of those who chose AIDS as the most urgent health problem facing this country at the present time in the third chart; 68 per cent of American respondents picked AIDS, 39 per cent of French and 13 per cent of Japanese shared the same view. On the basis of the correlation found in the figure, it can be inferred the greater the number of AIDS cases, the more prominent the view of the disease as an urgent health problem. The number of cases in France was relatively high in comparison with other major European countries such as Germany, Italy or the United Kingdom (see Table 1). Not only the absolute number of cases but also the number per inhabitant was remarkable. Given the correlation between the number and the view, France had a necessary condition for the construction of the threat perception.
Table 1

Size of HIV infections in major European countries in the late 1980s

 

31 December 1987

31 December 1990

 

Total number of declared cases

Per 1 million inhabitants

Total number of declared cases

Per 1 million inhabitants

France

3073

55

13 145

234

West Germany

1669

27

5612

71

Italy

1411

25

8227

143

The United Kingdom

1227

22

4098

71

Source: Steffen (1992, p. 223).

Despite the favorable conditions, however, the financial commitment of French government for the global fight was relatively low in comparison with the US until in the late 1980s. Additional determinants need to be examined to account for the construction of the perception, such as the role of media and civil society organizations.

The media’s role and attitude is significant in shaping the perception of the public, as public opinion tends to vary depending on how media frames agenda.5 Especially with respect to what is related to professional and medical knowledge, the media’s process that determines the view of the mysterious symptom can be elucidated twofold: first, the media plays a bridging role in conveying the findings of the medical community to the public. The French media helped the public understand the scientific and medical knowledge associated with HIV/AIDS, such as the cause and route of transmission of the disease.6 Second, and more importantly, the media attaches specific social and political meanings to the issue; an agenda is perceived differently depending on what political and social implications are ascribed and brought to the public sphere. The disease entered into the public sphere beyond the medical realm through the so-called naming process of the media. HIV/AIDS was distinctively named from the ‘gay disease’, ‘social phenomenon’ to ‘national cause’ in France.

In addition to the media’s role, civil society organizations mattered for constituting certain perception and policy developments. They not only educated and mobilized the public, but also created direct and/or indirect pressure on policymakers for establishing policies. Therefore, governmental responses to the disease ran parallel to the emergence of civil society organizations like AIDS community-based organizations (CBOs) or HIV/AIDS-related NGOs. For instance, civil society organizations dealing with HIV/AIDS in the US, consisting of a variety of minority groups vulnerable to the epidemic, such as gays, hemophiliacs and drug users, became active in the mid-1980s. They encouraged the media to correct the flawed notion of the public and policymakers. They also put pressure on government to enact the laws that increased research funds and expedited the approval process of regimen in the mid-to-late 1980s. Their activities were directed toward breaking the wall of social prejudice and discrimination against the already marginalized groups, which created more favorable social and political conditions for responding to the epidemic.7

The research illuminates the process that the media and civil society organizations became engaged in constructing the view of HIV/AIDS requiring urgent responses throughout the 1980s in France. The media’s role and the activities of civil society organizations were remarkable in redressing the misperception and stigma, as well as invigorating governmental interventions in France. The medical community played a significant role since the mid-1980s in conducting the medical research and triggering the awareness and interests of the public as well as government elites by providing the research findings. Subsequently, civil society groups dealing with HIV/AIDS emerged and developed dramatically up to over 1500 volunteers in 31 cities in the 1990s. They mobilized citizens for civil activities and lobbied for government policy establishments. The activism in the 1990s looked just like the enthusiasm in the US in the 1980s.

HIV/AIDS was distinctively named in accordance with the ways that the media framed it. Table 2 shows the distinctive naming in six national dailies (Le Monde, Libération, Le Martin, Figaro, Quotidien and Humanité), all of which had regular coverage dealing with medical issues by specialized journalists like doctors (Herzlich and Pierret, 1989). The naming (or framing) gives us an insight of how the perception changed, along with the responses galvanized. Following explains how the media and civil society groups attributed to the perception change in respective stages of distinctive framing.
Table 2

Number of articles regarding AIDS and naming in six French dailies

 

Number of newspaper articles (Le Monde, Libération, Le Matin, Figaro, Quotidien, Humanité)

Naming

The mysterious illness: 16 months

8

‘Gay disease’

(January 1982–April 1983)

(1.9%)

Construction of social phenomenon: 13 months (May 1983–May 1984)

83

‘Social phenomenon’

(20.1%)

A relative calm: 10 months

47

‘Social phenomenon’

(June 1984–March 1985)

(11.4%)

Gaining momentum: 15 months

274

‘National cause’

(April 1985–June 1986)

(66.5%)

Source: Herzlich and Pierret (1989, p. 1236).

The Mysterious Illness in 1982–1983: ‘Gay Disease’

Between January 1982 and April 1983, HIV/AIDS was named as the ‘gay disease’ in major French newspapers. The medical mystery, with uncertainty and perplexity, was covered in only eight articles during a 15-month period (Herzlick and Pierret, 1989, p. 1242). The disease was characterized based on its major route of transmission: homosexuality. The first victims of AIDS were gay men and homosexuals, both male and female, accounted for more than 60 per cent (79 out of 127) of total infections until 1983. The word ‘high-risk groups’ (groupes á risqué in French) was overly highlighted and became popular due to the high infection rate of gays and their sexual orientation (Herzlich and Pierret, 1989, p. 1238). As a result, the mystical medical symptoms were initially perceived as ‘homosexual pneumonia’, ‘homosexual cancer’, ‘gay cancer’ or, more frequently, the ‘homosexual syndrome’. The core symbolic connotation was so strongly attached that the topic of homosexuality remained in the discourse on HIV/AIDS until July 1983 (Herzlich and Pierret, 1989, p. 1242).

When it comes to civil society organizations, it was hard to see active social groups that worked on HIV/AIDS in France in the early 1980s. Historically, France did not have a tradition of active CBOs, unlike some English-speaking countries, such as the US, Canada and Australia, having a strong culture of social solidarity.8 As a result, the French gay community was very disorganized and even invisible at the outbreak of the epidemic. In addition, sexuality was not recognized as something to be discussed as a public issue. The already marginalized group was stigmatized due to the alleged correlation between their sexual orientation and AIDS. Steffen comments that:

[T]he French homosexual community was initially not prepared to take up the AIDS problem which caused great uncertainty about the future of the community, [and] fear of renewed marginalization. (Steffen, 1993, p. 245)

It was the mid-1980s when the social and political aspects were illuminated beyond the misperception of the ‘gay disease’. The ‘social phenomenon’ framing was feasible due to the roles of the media and the emerging civil society organizations.

Construction of Social Implications in 1983–1984: ‘Social Phenomenon’

During the period between May 1983 and May 1984, HIV/AIDS was reframed in the dailies as a ‘social phenomenon’ that had impacts on everyone, instead of a medical mystery associated only with certain isolated groups. The number of AIDS-related articles in the French dailies increased dramatically and contained a large variety of writing styles, such as reportages, interviews and commentaries. Eighty-three articles covered diverse topics from objective scientific research findings to social and political dimensions of the epidemic (Herzlich and Pierret, 1989, p. 1237).

First, the dailies relied on scientific findings from the WHO, the Center for Disease Control (CDC) and the French Ministry of Health in a descriptive and informative (even dry) tone. The way this unknown and unexplainable medical event was covered helped to prevent dramatization and sensational (or emotional) reactions to the spread of the epidemic.9 Using information provided by the WHO, the coverage introduced the quantitative data and the extended trajectory of the disease’s proliferation. The gloomy picture provided by the statistics established the caution that something needed to be done to curb the catastrophic prospect of the emerging pandemic (Herzlich and Pierret, 1989, p. 1237). The dailies also delivered the survey of the CDC on the nature of the victims and the routes of transmission. The public became aware of the feature and identity of the disease, correcting the misunderstanding of the relations between homosexuality and the disease. The media coverage on the scientific research and statistics from the reliable sources shaped the understanding that it was not an issue of people with certain sexual orientation but something that posed a threat to everyone if not responded to immediately.

HIV/AIDS became treated as ‘social phenomenon’ also because of the way that the dailies touched upon the first isolation of the virus in 1983 – an event declared as a scientific breakthrough.10 When the first discovery of the virus was announced, the dailies pinpointed not only scientific information but also events with socioeconomic dimensions, such as the so-called ‘virus quarrel’ between the US and France for patent and research funds.11 The disease became popular as ‘the economic spin-offs of AIDS – the patents for tests or future vaccines, the competition for shares of the market’ was meticulously covered (Herzlich and Pierret, 1989, p. 1238). As a result, it fell into the category of a ‘fact of society’ (in French journalistic jargon fait de société) beyond the medical realm from the Summer of 1983 on.

The ‘virus quarrel’ was well covered particularly because the French biomedical community was directly involved in the research from a very early stage. The community, including the Association for Research on AIDS (ARSIDA) and the Association of Gay Physicians (AMG), had begun to conduct research on the origin of AIDS since the year 1983. ARSIDA originated from a small informal group of researchers and doctors who were curious about the new medical phenomenon. Dr Rozenbaum encountered the first AIDS cases in a hospital located in the Paris area in 1981. He soon speculated that the mysterious medical symptoms might be compatible with the first cases in the US, introduced in the Morbidity Mortality Weekly Report (MMWR) in June. As more similar symptoms were reported, he and his young colleagues felt alarmed and set up a small informal unit to examine scientific literature and case materials. The participation was not limited to medical doctors. Experts from related disciplines, such as the virologist Françoise Brun-Vezinet, the immunologist Jacques Leibowitch and the psychiatrist Didier Seux, got involved in the examinations. More people from diverse backgrounds, including psychiatrists, epidemiologists and immunologists, joined the unit so that it developed as a working group, formally recognized later by the General Department of Health in the Ministry of Health in early 1982 (Pollak, 1990, pp. 79–80).

The working group participated in the research project for the isolation of the HIV virus in collaboration with the Pasteur Institute. Dr Rozenbuam provided the Institute with his patients’ sample of a lymph node. The Luc Montagnier’s group in the Institute succeeded in isolating the virus and named it LAV in 1983 (Pollak, 1990, p. 80; Steffen, 1992, p. 232). The group, subsequently, was divided into two sub-units; one for epidemiology and the other for clinical and social research. Dr Montagnier was assigned the leadership of the latter. He reorganized it as a separate association and named the Association pour la Recherche contre le Sida (ARSIDA) in 1983. The ARSIDA consisted of the professionals from the health and medical fields from the Pasteur Institute, the National Institute for Health and Medical Research (IMSERM) and hospital doctors working on AIDS (Pollak, 1990, p. 83). The ARSIDA became an internationally recognized medical community and appointed as a center for AIDS research in Europe by the WHO in October 1983. In November 1984, it was transformed into the European Center for Epidemiological Monitoring of AIDS in Paris based on the agreement between the French government and the WHO (Steffen, 1993, pp. 246–247).

Despite the efforts of the media and the medical community, there were very nominal and minimal governmental policy interventions. The first official policies were suggested in the Summer of 1983. The General Department of Health published recommendations such as the hygiene and security measures of health workers; the cautions against the risk groups consisting of gays, intravenous drug users and those who had African and Caribbean origin and their parents in the blood transfusion centers; and a monitoring system to figure out the prospect of the development of the disease for preparing an intervention structure. In addition, the National Institute for Health, Medical Research and Technology and the Foundation for Medical Research also allocated funds for AIDS research.

The recommendations did not lead to tangible policies due to the lack of definite medical knowledge and the absence of the sense of urgency to respond to the medical phenomenon whose impact and prospects remained unexplored. There was a feud within the General Department of Health, between medical professors of cancer and immunology and other expert groups in the Department, as to whose responsibility it was to conduct research (Steffen, 1993, pp. 246–247). In addition, health issues were not subject to be put forward within the French bureaucratic system due to the inferior position of the health administration in the hierarchical ladder. An unknown health agenda like HIV/AIDS was almost impossible to be prioritized in the system in the early-to-mid 1980s. The new Chirac regime did not even appoint any personnel in charge of public health until 1986. The mood of inaction associated with the lack of clear understanding of HIV/AIDS began to change in the mid-1980s.

Gaining Momentum in 1985–1986: ‘National Cause’

HIV/AIDS was framed as a ‘national cause’ between April 1985 and June 1986 (Herzlich and Pierret, 1989, p. 1242). During this period, there were several focusing events, which the media fiercely covered and brought about heated debates. The coverage of the controversial issues opened the window of opportunities, during which HIV/AIDS became recognized as a national agenda. Civil society organizations, such as AMG and AIDES, also played a critical role in the process of the perception change.

The first focusing event was on so-called ‘healthy carriers’ or porteurs sains. In the aftermath of the discovery of the HIV virus in 1983, people mostly understood HIV as a cause of AIDS. However, the medical community found that there were some people who were HIV-positive but had antibodies. Those people were called ‘seropositive’ or séropositif. The frequent exposure of the issue provoked confusion and stigmatization among the public against all HIV-positive regardless of the status of antibodies due to the absence of clear understanding and the preconceived notion of the disease as being in line with homosexuality and ‘casual contacts’ transmission. The media soon became devoted to challenge the misperception and stigma. The newspaper articles educated the public about the identity of the disease, especially regarding the equivalent propensity of heterosexual transmission through unprotected sexual contacts. They were enlightened that the epidemic was for everyone, not for a small fraction of the population with specific sexual orientation (Herzlich and Pierret, 1989, pp. 1239–1240).

Testing blood donors and other related debates also brought HIV/AIDS into the public sphere. Prime Minister Laurent Fabius announced that all blood donors would be subject to obligatory testing after the first of August in 1985 (Bosia, 2006, p. 650). The debate was framed as a dilemma between government intervention for public health versus individual human rights and privacy. The media served as a major venue for the debate, especially on how to inform blood donors of test results when they turned out HIV-positive. The public paid attention and determined AIDS as something that needed to be publicly discussed and responded at the national level (Herzlich and Pierret, 1989, p. 1240).

The media coverage of the stories of well-known people with HIV also enhanced understanding of the disease’s social implications. For instance, the public’s attentions were given to the death of a famous Hollywood actor, Rock Hudson, due to AIDS in July 1985. His story was covered by the French dailies because of his visits to France to receive special medical treatments before he died. The dailies also shed light on the death of Michel Foucault, a famous gay scholar and activist. He had frequently appeared in the media to raise funds for AIDS research and advocate for public awareness (Pollak, 1994; Bosia, 2007). The media coverage illuminated his past activities and accomplishments in the context of human rights of gays and the HIV-positive. The events paved a way for HIV/AIDS to be recognized as an issue that deserved social and political discourse and policy responses at the national level.

The roles of civil society organizations12 were also crucial in shaping the view that a whole society needed to grapple with the agenda as a national cause. First, a gay medical expert group, named AMG, educated the public as well as gays regarding the scientific knowledge about the identity and the mode of transmission of HIV. They emphasized that gays were exposed to the higher probability of infection due to their risky sexual behavioral patterns. At the same time, they publicly claimed general preventive measures for both heterosexuals and homosexuals: ‘[A]s far as prevention is concerned, limiting the number of sexual partners, abstaining from blood donation and using condoms seem to be the only reasonable measures’ (Pollak, 1990, p. 84). Their activities were geared toward transforming the attitude and behavior of the public as well as gays.

Another private association, named AIDES,13 also shifted the perception and galvanized government responses. Founded at the end of 1984, AIDES attempted to ‘de-dramatization’ of AIDS in time of uncertainty and stigma. Daniel Defert, the founder of the association, understood that ‘AIDS was an issue that could not for long be confined to the status of medical problem’ (France, 2002, p. 13). He regarded it as the disease of everyone, not one for a specific group with a certain sexual proclivity, which should be dealt with like other social and political agendas given its public distress and sexual discrimination. AIDES aimed to represent the interests of all AIDS victims regardless of sexual orientation, including gays, heterosexuals, acute patients and healthy carriers.

AIDES became active in early 1985 in leading the discourse and mobilizing gays and health professionals alliances for social and political movements against discrimination of homosexuality and HIV-positive (Pollak, 1990, p. 85). AIDES developed a community-based education program in order to enhance the awareness of the disease as ‘a general cause’ among healthy carriers and AIDS patients. Defert stressed that those suffering from the disease should absorb medical information with an ownership of the knowledge in the process of ‘de-dramatization’ (France, 2002, p. 13). The education program was also geared toward recruiting opinion leaders among the public for social movements. The program contributed ‘to promote solidarity with patients, to spread information and to establish preventive measures both against the epidemic and against the risk of group stigmatization’ (Steffen, 1993, p. 248).14 Many celebrities in France and from the US, such as Liz Taylor, were involved in the movements.

AIDES, as a pressure group, pushed government for policy responses. The association launched free test facilities by itself, distributed condoms in gay meeting places and organized public conferences that urged the sale of syringes. The activities were encouraged by the AIDS-conscious officials in the Ministry of Health who could not echo their voice publically but shared a belief of the necessity of policy reform (Steffen, 1992, pp. 236–248). AIDES, along with the National Transfusion Society, the National Commission on Transfusion and the National Committee on Ethics, suggested several policies, from which the government took two administrative measures: compulsory testing of donated blood and blood products, and the compulsory registration of AIDS cases. When compulsory testing was initiated in August 1985, 1 in 1000 blood donors were found infected, which meant that 50 000 French people might have already been infected in 1985 (Steffen, 1992, pp. 234–235). The policies might not have been major government actions but could be considered as catalysts for future policy changes from 1996 on.15 Herzlich and Pierret (1989) thus named this period as ‘gaining momentum’ in which media events, medical discovery and the activities of AIDES created a condition for policy development for the national cause (p. 1240).

Institutionalization of AIDS Policy since 1986

Major government policies were launched in 1986, along with the dramatic perception changes. Most notably, the view was reflected in the official announcement of a newly appointed Health Minister Michelle Barzach, who declared AIDS as a ‘national cause’ in a forum in the second International AIDS Conference in Paris on 10 June 1986. HIV/AIDS became recognized as the disease needing immediate responses at the national level, as it was added to the list of ‘compulsorily notifiable diseases’ (Steffen, 1992, p. 237). Pollak (1990) reverberates that ‘AIDS did appear among the major identified problems that our society has to face’ (p. 86).

The medical community participated in policy reform. Their voice resonated more within the related government apparatus after the isolation of the second HIV virus in the Pasteur Institute in February 1986. Medical experts from various associations including AIDES worked closely with the Ministry of Health to draft documents on the new challenge. The first document produced by them was so-called Rapin Report, which illuminated the scientific and social problems posed by HIV/AIDS and urged responses to the imperative public health agenda (Steffen, 1992, p. 237). A new government, a right-center coalition between Gaullists (RPR) and Giscardians (UDR), adopted the Report as a blueprint for new policies and appointed Michelle Barzach as Health Minister as recommended by the Report (Pollak, 1990, p. 88).

Many changes were made in government policies under her new leadership and suggestions of the Report. In November 1986, she attempted to legislate new AIDS prevention policies for the year 1987 such as promoting international collaboration, funding for research on treatment and vaccines; creating a special research council and nominating Professor Alain Pompidou as ‘Mr AIDS (Monsieur AIDS)’, also known as the AIDS policy coordinator; creating an advisory unit in charge of social ethical issues; developing facilities for medical care and testing; and initiating public information campaigns. Moreover, a special annual budget for HIV/AIDS response was allocated for the first time: ‘$18 300 000 for research for two years; a $6 600 000 supplementary budget allowance for Paris hospitals; a subsidy of $80 000 for the private organization AIDES, twenty-three special AIDS centers were established during 1987, and eighty-eight more for the provision of information, treatment, and prevention services’ (Steffen, 1992, p. 238).

In 1987, the French government also took some measures for educating the public and establishing anonymous test sites. With respect to the education, the government conducted a national information campaign on AIDS. Around 24 million brochures were mailed directly to households, and 13 million leaflets were circulated through the social services, pharmacists and general practitioners. The government was very cautious about not stigmatizing the public; ‘avoiding addressing explicitly the issues of (homo)sexuality, drug consumption, and AIDS-related practices’ (Pollak, 1990, p. 89). In addition, the Health Minister announced in the International Conference on AIDS in Washington DC that they planned to set up anonymous test sites in June 1987. The government worked with civil society organizations to establish test sites in Paris and Lyon (Steffen, 1992). Steffen (1992, pp. 248–249) argues the campaigns and the ‘voluntary, free and anonymous testing facilities’ contributed to relieving fear, panic and anxieties of the public and more importantly promoting safe sex habits in the general population.

There was a significant leap in policy changes beyond public education and test sites in 1988 and 1989. The changes were launched along with an appointment of the new Health Minister, Claude Evin, in 1988. The Minister made an official announcement on his perception that ‘AIDS was no longer a disease of a particular group but concerned everyone’ in the National Plan against AIDS in November 1988 (Steffen, 1993, p. 257). He also understood HIV/AIDS as ‘broad social and ethical challenges’ (Steffen, 1992, pp. 241–243). On the basis of this view, he recruited Professor Claude Got to vitalize governmental efforts. Dr Got produced the first official and public document on AIDS, the so-called Got Report. In the Report, he reconfirmed the view of HIV/AIDS as a pandemic that threatened public health not confined to gays or hemophiliacs. He also criticized the lack of preparation of the French health system to cope with it, such as understaffing of the Health Department. The Report recommended a minimum of two staff positions exclusively assigned to AIDS responses. It also raised the issue of funding for clinical and pharmaceutical research to be raised at least US$25 000 000 a year. The funds increased dramatically at four times; from $5 million to $20 million within 1 year from 1988 to 1989.

The Report claimed the importance of establishing an overarching national agency that encompassed all related governmental activities. In conformity with the suggestion, a National Agency for AIDS Prevention was created in January 1989. The Agency was in charge of designing and revitalizing various prevention efforts including mass education campaigns. The agency was created by the Ministry of Health, but assigned the official status of a private association having autonomy from the government from decision making to policy implementation. The unique administrative status was given because the government was reluctant to directly deal with AIDS-related issues due to its ethical and political characteristics. The government wanted to take a bold step in grappling with the urgent health crisis through the private association, without touching upon the complications, in order not to stigmatize the public (Steffen, 1992, pp. 243–244).

Conclusion

The study examines the process that domestic determinants constructed the perception of HIV/AIDS for global funding development in France in the mid-to-late 1980s. The determinants shaped the perception of threats requiring immediate international cooperation among the public and the government elite. This view played a role as an intervening variable that conditioned the domestic internalization of international norms of the global response to HIV/AIDS.

The research particularly delves into how such domestic factors as the media attitude and the role of civil society organizations determined the views on the epidemic. The French media bridged the gap between the medical community and the public’s understanding of the disease by introducing such scientific findings as the origin of the disease or identification of the virus causing AIDS. The educating role helped to correct misperception about the medical mystery and to de-dramatize the stigma associated with the pandemic. The media also crafted the perception beyond the medial perspective toward social phenomenon and a national cause by dealing with such controversial issues as the origin of the disease, identification of the virus causing AIDS, a patent battle against the US and the status of healthy carriers.

Despite the historical backgrounds of weak civil societies, the medical community and gay advocacy groups were crucial in enlightening the public and the elites and exerting influence on government policymaking. ARSIDA and AMG not only conducted research but also educated the public on the new infectious disease in the 1980s. It was in the late 1980s that French gay community groups like AIDES emerged and made the AIDS agenda salient by mobilizing the public as well as gays. AIDES built a network with specialists, who sought to prevent public stigmatization and marginalization of gays by designing and implementing government measures (Altman, 1994, p. 37). The organization also put pressure on the government apparatus for more active responses. They provided policy recommendations and actively participated in the process of drafting reports, such as the Got Report and the Rapin Report, both of which were crucial as references for policymakers to develop policies.

The research contributes to the studies of international norms and domestic determinants for foreign policy choices. The findings of this study show how domestic factors that shaped perception conditioned foreign aid policy development. The study will be stretched toward examining domestic resonance of international norms and foreign policy establishment in other policy areas. In essence, this type of approach can examine the dynamics and process of norm diffusion by highlighting under what domestic conditions international norms likely proliferate or are hampered. In addition, the research paves the way for scrutinizing issues with scientific uncertainty or ethical (sexual) implications. The lessons about the process of framing in which certain social, cultural or/and political meanings are attached to the perception will be suggestive to the study of policymaking for other medical or scientific agenda with equivalent features.

Footnotes

  1. 1.

    On 5 June 1981, the CDC reported five cases of Pneumocystis carinii pneumonia in homosexual males in Los Angeles in MMWR (CDC, 1981, pp. 250–252).

  2. 2.

    More details of the role of the WHO and international norms for global fight against HIV/AIDS can be found in Mann (1987), Mann and Kay (1991), Merson (2006), Slutkin (2000) and Will (1991).

  3. 3.

    France was reluctant to make progress in foreign aid for HIV/AIDS in comparison with other major contributors such as the US, Sweden or Canada at the early stage. However, France was more active in the global response than the Netherlands, Germany or Japan.

  4. 4.

    For more research on the ‘match’ between international norms and the domestic understanding, see Checkel (1999), Cortell and Cavis (2000), Gurowitz (1999) and Risse-Kappen (1991). They discuss the resonance of international norms and domestic conditions with the concepts of ‘cultural match’, ‘domestic salience’ or ‘domestic structure’.

  5. 5.

    See Rioux and Van Belle (2005) for scholarly discussions on the influence of the media on French foreign aid policy choices.

  6. 6.

    The six dailies began to use the term AIDS (SIDA in French) instead of ‘cancer’ in March 1983.

  7. 7.

    Such perception changes were also made in Japan as new civil society organizations emerged in the early 1990s. See Kim (2015b) for more details.

  8. 8.

    The US has had strong gay movements in civil society organizations based on the culture of volunteerism. However, French citizens were unwilling to participate in voluntary works so that the emergence of AIDS organizations lagged (Altman, 1994, pp. 22–23). At the same time, France has a strong state with a unitary political structure and central bureaucracies who have played powerful and independent roles in policymaking (Safran, 1985, p. 147; Van Belle et al, 2004, p. 65). As a result, there were few opportunities for the civil society groups associated with HIV/AIDS to be involved in policymaking in the early 1980s in France.

  9. 9.

    The attitude of French media seems particularly suggestive when compared with the cases of Japan. Japanese media sensationalized the agenda so that Japanese people were traumatized by the false information. For the details of the attitude of Japanese media regarding HIV/AIDS, see Dearing (1992), Feldman and Yonemoto (1992), Treat (1999), Ikeda (1995), Sawazaki (1997) and Kim (2015b).

  10. 10.

    Before the discovery of HIV by Dr Montagne in 1984, there was debate on what causes the disease and how it is transmitted between the retroviral hypothesis versus the immunity hypothesis. So-called retroviral hypothesis argued that ‘AIDS is an infectious disease caused and transmitted by a viral agent’. The immunity hypothesis, however, claimed that AIDS is ‘an immune deficiency, the consequence of a multiplicity of assaults on the body’s disease-fighting capacity’ (Steffen, 1992, pp. 232–233). Dominant experts groups advocated the immunity hypothesis yet only minority specialists defended the retroviral hypothesis (Pollak, 1990, p. 84). The scientific breakthrough proved the minority opinion of retroviral hypothesis was scientifically correct.

  11. 11.

    The tension was heightened when the American Secretary of State for Health made an announcement on the discovery of the virus in the US. Even though the patent was filed by the French team earlier than the US team, a patent was granted to the US while the French petition remained unanswered. The tension resulted in the legal struggle in 1985 (Steffen, 1993, p. 248).

  12. 12.

    The role of civil society organizations was not limited to the public education. Many social groups provided specialized services for HIV-infected. For example, the Groupe AIDES Prison launched education services about the rights of the infected prisoners. A larger AIDS organization, the Association pour les Appartements de Relais Therapeutique et Social, provided housing for people with AIDS who were ousted due to the infection (Pollak, 1990, p. 85; Atlman, 1994, p. 40).

  13. 13.

    The name of the association, French word aides, means ‘help’ in English but sounds like AIDS. This is a word play having dual meanings of help and AIDS.

  14. 14.

    An AIDES pamphlet says that ‘one alone cannot change his or her behavior: a social movement and opinion leaders are needed’ (Altman, 1994, p. 43).

  15. 15.

    There were few major government policies before 1986 due to the attitude of the socialist government, which attempted to keep the issue out of the sight of the public. First, the government wanted to circumvent public panic. At the same time, it was afraid of being accused of demographic indifference (associated with low birth rate) and favoring drug addiction if it had established policies that liberalized the distribution of condoms and the sale of syringes (Pollak, 1990, p. 87; Steffen, 1992, p. 236).

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Copyright information

© Palgrave Macmillan, a division of Macmillan Publishers Ltd 2016

Authors and Affiliations

  • Young Soo Kim
    • 1
  1. 1.Department of Political ScienceLoyola University New OrleansNew OrleansUSA

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