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Inequalities in health care: Problems of access and provision
Book reviews
bureaucracy: the Treasury. This department has been the domain of a succession of extremely powerful and skilful bureaucrats. It is not an exaggeration to say that Australia’s economic development has been controlled for generations by a coterie of civil servants. While Jones and Stilwell’s arguments are convincing, the paradox remains: urban planning for some has succeeded too well; for others, not at all. Of course, these authors are not discussing the same issues-but that also is interesting. Allport’s perspective on women’s structured life in the suburbs hardly intersects with the (male) world of federal policy elites. Thus the paradox is not simply of facts, it is of perspectives and politics. Davidson’s essay on urban planning in Melbourne in the early decades of this century has much more in common with Allport, being concerned with the structuration of everyday life by social institu tions. Thus, it seems that a large part of the difference between these perspectives is as much theoretical, albeit often unstated. For example, the ‘everyday life structuration’ argument conceives of society in very different terms than the elite-comrol argument. For proponents of the former ~gurne~, ~~ct~ti~ permeates the whole fabric of social life. It is not simply direct state activity that is the issue, rather the entire arrangement of society that both encompasses the state and provides its r&on d’&e. I believe the issue to be theoretical, and Chris Paris says as much in his review of Saunders, Castells, and Dunleavy. The existence of ‘urban politics’ in Australia remains an open question. And, Paris’ brief review goes some way to indicate the points of contention and similarity in the current crop of urban social theorists. Interestingly enough, Paris would agree with Jones and Stilwell in that he argues that bureaucratic centralization has been the dominant trend in fern-sate-lo-govemmental relations. The local state is powerless in the face of tremendous fiscal, legal and developmental imperatives sustained by the federal government. Again, there is a question of perspective and theoretical position, with Paris et al. being clearly more impressed with the instrumental arrangement of institutional powers than more subtle forms of social structuration. Saunders’ long and discursive treatment of Weber is of course related. I-Es essay in this book argues for Web&an social theory rather than Marxian social theory. Like Paris, some of his argument rests on ~p~~-~rn-~~i~ti~~ observations. The separation of the political and economic spheres is well articulated, as well as the bureaucratic character of the state. Saunders
177
rightly notes that Weber has been mistakenIy criticized as an ‘idealist’, as opposed to a ‘realist’. And his use of Weberiau categories is weIl done. In terms of the previous essays reviewed here, Saunders’ approach sits well with Jones and Stilwell, perhaps even with Paris (which should surprise him); less well, however, with Allport and Davidson. Again, it is a question of theory and perspective; an issue not adequately recognized by Saunders. Two other major essays are included in this volume. J. Brian McLaughlin laments the crisis in British urban planning and education. Why his essay was included is difficult to say. The half-hearted attempt to link Thatcher and Fraser fails and in terms of recent events in Australia {the election of the Labour government) looks superficial. It hardly addresses the real differences between Australia and Britain, and again looks like an outsider imposing a blueprint on Australia. Chris Maher’s paper on internal migration is very good and interesting. His theory of policy is, however, very much the rational planning model. More information, better information, and new information will presumably make a difference. Of course, such an gumption hardly recognizes the subtleties introduced by the other writers in this book. I have to say, however, that my criticism may be a little unfair, given the more narrow issue he considers. Yet the point remains to be made. There are a couple of extended book reviews of recent Australian urban research, and a brief report on current planning practice. These will undoubtedly interest Australian readers and perhaps others interested in tracing the develop ment of current cross-national research. Overall, this volume was very well put together and one hopes that it will become a major forum for urban research in the future. Gordon L. Clark
Inequalities in Health Care: Problems of Access and Provision, J. Whitelegg, Straw Barnes,
1982, 159 pp., 26.95 (paperback). In this book, John Whitelegg sets out to explore the relationships between health inequalities as measured by occupational status and accessibility as manifested in the use of hospital facilities. He wishes to locate the traditional geographical problem of accessibility within its broader societal context because the nature of capitalist economic and social relations and of
178
Book reviews
the provision of care in such societies critically affects the availability of and access to health resources. Such a view is both important and intuitively correct. To put these ideas into establishes ‘a common practice, Whitelegg framework’ by examining inequalities in health, education, income, housing and employment. These inequalities are not treated as isolated problems but as a collectivity of conditions which is a part of the lives of certain individuals and households. His discussion is both interesting and lucid. It is, however, when we move from ‘inequalities’ to ‘accessibility’ that certain disjunctures appear. The author recognizes that accessibility is often a crude surrogate, that there is a mismatch often between needs and ability to obtain scarce resources and that bargaining power in the market is crucial. These problems are, however, ‘quite often problem(s) of access’. Such a conclusion allows for a conventional geographical discussion on the issues of accessibility, albeit within the holistic framework of Hagerstrand’s time geography. Moreover, the empirical research is a fairly straightforward study of patterns of travel behaviour which ends with ‘the modelling exercise’ in which the possibility of a health authority’s (Blackburn’s) strategic plan affecting travel and transportation is assessed. Not only are the authority’s aims taken as given (a view out of step with the notions in the rest of the book) but there is also an important limiting assumption in the exercise which Dr Whitelegg himself recognizes. The exercise assumes that demand is independent of facility location. Such a state of affairs is true for neither patients nor their visitors. After the reporting of the empirical material, there is a critical discussion of the health authority’s
strategic plan. This criticism is well made, suggesting that the administrative and medical ethos and mores behind such documents may militate against the reduction of inequality. The author does not stop at criticism but suggests ways in which inequalities may be reduced faster, citing alternative medicine and greater individual responsibility as possible forms of positive a&on. The dangers of the ccoptation of alternative medicines by their commercialization and of individual encouragement resulting in greater self-help and private provision of health care remain unrecognized. Indeed, the remainder of the chapter on positive action is a little disappointing. It looks not at the practices of societies but at the recommendations of academics and government working parties and reports. It may have been more telling for his argument if Whitelegg had looked at the health care policies of Cuba, China, the Soviet Union and Tanzania. He concludes his book by again advocating a broad framework for understanding and tackling health inequalities. In this, accessibility is seen as a vital ingredient. We should, in fact, concur with the importance of the geographical perspective, although a critical level is the production of resources (i.e. resource allocation) and not just accessibility. Overall, then, this book is an interesting and stimulating read. It is marred by the juxtaposition of societal issues and accessibility. In other words, this relation is asserted rather than demonstrated. It is, however, wide-ranging with an interesting case study of travel behaviour. I recommend it. John Eyles Department of Geography Queen Mary College, University of London
bureaucracy: the Treasury. This department has been the domain of a succession of extremely powerful and skilful bureaucrats. It is not an exaggeration to say that Australia’s economic development has been controlled for generations by a coterie of civil servants. While Jones and Stilwell’s arguments are convincing, the paradox remains: urban planning for some has succeeded too well; for others, not at all. Of course, these authors are not discussing the same issues-but that also is interesting. Allport’s perspective on women’s structured life in the suburbs hardly intersects with the (male) world of federal policy elites. Thus the paradox is not simply of facts, it is of perspectives and politics. Davidson’s essay on urban planning in Melbourne in the early decades of this century has much more in common with Allport, being concerned with the structuration of everyday life by social institu tions. Thus, it seems that a large part of the difference between these perspectives is as much theoretical, albeit often unstated. For example, the ‘everyday life structuration’ argument conceives of society in very different terms than the elite-comrol argument. For proponents of the former ~gurne~, ~~ct~ti~ permeates the whole fabric of social life. It is not simply direct state activity that is the issue, rather the entire arrangement of society that both encompasses the state and provides its r&on d’&e. I believe the issue to be theoretical, and Chris Paris says as much in his review of Saunders, Castells, and Dunleavy. The existence of ‘urban politics’ in Australia remains an open question. And, Paris’ brief review goes some way to indicate the points of contention and similarity in the current crop of urban social theorists. Interestingly enough, Paris would agree with Jones and Stilwell in that he argues that bureaucratic centralization has been the dominant trend in fern-sate-lo-govemmental relations. The local state is powerless in the face of tremendous fiscal, legal and developmental imperatives sustained by the federal government. Again, there is a question of perspective and theoretical position, with Paris et al. being clearly more impressed with the instrumental arrangement of institutional powers than more subtle forms of social structuration. Saunders’ long and discursive treatment of Weber is of course related. I-Es essay in this book argues for Web&an social theory rather than Marxian social theory. Like Paris, some of his argument rests on ~p~~-~rn-~~i~ti~~ observations. The separation of the political and economic spheres is well articulated, as well as the bureaucratic character of the state. Saunders
177
rightly notes that Weber has been mistakenIy criticized as an ‘idealist’, as opposed to a ‘realist’. And his use of Weberiau categories is weIl done. In terms of the previous essays reviewed here, Saunders’ approach sits well with Jones and Stilwell, perhaps even with Paris (which should surprise him); less well, however, with Allport and Davidson. Again, it is a question of theory and perspective; an issue not adequately recognized by Saunders. Two other major essays are included in this volume. J. Brian McLaughlin laments the crisis in British urban planning and education. Why his essay was included is difficult to say. The half-hearted attempt to link Thatcher and Fraser fails and in terms of recent events in Australia {the election of the Labour government) looks superficial. It hardly addresses the real differences between Australia and Britain, and again looks like an outsider imposing a blueprint on Australia. Chris Maher’s paper on internal migration is very good and interesting. His theory of policy is, however, very much the rational planning model. More information, better information, and new information will presumably make a difference. Of course, such an gumption hardly recognizes the subtleties introduced by the other writers in this book. I have to say, however, that my criticism may be a little unfair, given the more narrow issue he considers. Yet the point remains to be made. There are a couple of extended book reviews of recent Australian urban research, and a brief report on current planning practice. These will undoubtedly interest Australian readers and perhaps others interested in tracing the develop ment of current cross-national research. Overall, this volume was very well put together and one hopes that it will become a major forum for urban research in the future. Gordon L. Clark
Inequalities in Health Care: Problems of Access and Provision, J. Whitelegg, Straw Barnes,
1982, 159 pp., 26.95 (paperback). In this book, John Whitelegg sets out to explore the relationships between health inequalities as measured by occupational status and accessibility as manifested in the use of hospital facilities. He wishes to locate the traditional geographical problem of accessibility within its broader societal context because the nature of capitalist economic and social relations and of
178
Book reviews
the provision of care in such societies critically affects the availability of and access to health resources. Such a view is both important and intuitively correct. To put these ideas into establishes ‘a common practice, Whitelegg framework’ by examining inequalities in health, education, income, housing and employment. These inequalities are not treated as isolated problems but as a collectivity of conditions which is a part of the lives of certain individuals and households. His discussion is both interesting and lucid. It is, however, when we move from ‘inequalities’ to ‘accessibility’ that certain disjunctures appear. The author recognizes that accessibility is often a crude surrogate, that there is a mismatch often between needs and ability to obtain scarce resources and that bargaining power in the market is crucial. These problems are, however, ‘quite often problem(s) of access’. Such a conclusion allows for a conventional geographical discussion on the issues of accessibility, albeit within the holistic framework of Hagerstrand’s time geography. Moreover, the empirical research is a fairly straightforward study of patterns of travel behaviour which ends with ‘the modelling exercise’ in which the possibility of a health authority’s (Blackburn’s) strategic plan affecting travel and transportation is assessed. Not only are the authority’s aims taken as given (a view out of step with the notions in the rest of the book) but there is also an important limiting assumption in the exercise which Dr Whitelegg himself recognizes. The exercise assumes that demand is independent of facility location. Such a state of affairs is true for neither patients nor their visitors. After the reporting of the empirical material, there is a critical discussion of the health authority’s
strategic plan. This criticism is well made, suggesting that the administrative and medical ethos and mores behind such documents may militate against the reduction of inequality. The author does not stop at criticism but suggests ways in which inequalities may be reduced faster, citing alternative medicine and greater individual responsibility as possible forms of positive a&on. The dangers of the ccoptation of alternative medicines by their commercialization and of individual encouragement resulting in greater self-help and private provision of health care remain unrecognized. Indeed, the remainder of the chapter on positive action is a little disappointing. It looks not at the practices of societies but at the recommendations of academics and government working parties and reports. It may have been more telling for his argument if Whitelegg had looked at the health care policies of Cuba, China, the Soviet Union and Tanzania. He concludes his book by again advocating a broad framework for understanding and tackling health inequalities. In this, accessibility is seen as a vital ingredient. We should, in fact, concur with the importance of the geographical perspective, although a critical level is the production of resources (i.e. resource allocation) and not just accessibility. Overall, then, this book is an interesting and stimulating read. It is marred by the juxtaposition of societal issues and accessibility. In other words, this relation is asserted rather than demonstrated. It is, however, wide-ranging with an interesting case study of travel behaviour. I recommend it. John Eyles Department of Geography Queen Mary College, University of London