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Infants, mothers and doctors
Book reviews and the opinions expressed are authoritative. For example, he reviews studies published "L~ustten years ago and opines that because of the consent process and use of placebos, many participants in them "might well have had a good cause of action in a malpractice suit". As for the future, Stone foresees an avalanche of lawsuits by patients who have developed tardive dyskinesia from drug treatments: "I personally have no doubt of the outcome, and surely the disfigurement of tardive dyskinesia will lead juries to grant large awards". A pervasive topic is the question of what measures, in addition to reliance on informed consent, are needed to insure that research on the mentally disabled is ethical. There are two primary proposals. One is for a patient "surrogate", either a single person or a committee, to act as an adviser to the IRB in devising the consent protocol, .and as an adviser to the subjects who are asked to consent. The second is for a "subject advocate" who would be more active with the IRB and would, during the consent process and experiment itself, act to help the subject not only understand the experiment, but also to resist enrollment where appropriate, and terminate his participation in the experiment whenever the subject wanted. IRBs as currently structured and financed cannot guarantee the welfare of subjects or the quality of their consent. New mechanisms are necessary, especially when dealing with "special populations" like prisoners, children and mental patients. The issues discussed in this volume remain unresolved, and uncritical acceptance of the effectiveness of IRBs will not make them go away.
Dept. of Socio-Medical Sciences and Community Medicine Boston University School of Medicine MA, U.S.A.
GEORGE J. ANNAS
Infants, Mothers and Doctors, by EUGENE B. GALLAGHER. Heath, Lexington, MA, 1978. 220 pp. $18.00 VIEW 1: FROM THE PHYSICIAN The transformation of the general practitioner from a sentimental, historical fiction to an active agent for social change has rejuvenated the popularity of family practice and brought in its wake a demand for information about families--their health care and their needs. Thus reviewing Eugene B. Gallagher's book with its catchy title, Infants, Mothers and Doctors, seemed a worthwhile task. I looked forward to learning something to supplement my Anglophilic reliance on the Opie's, the Newson's, and Pinchbeck and Hewitt. I was disappointed. The book is tedious and does little more than enumerate common knowledge. The writing is tendentious and humorless. At this point any wise reader will quit reading this review to save further waste of time. I, having read the book--all 200 lackluster pages of it--must earn my r eviewer's copy by saying what the book is about and why I didn't like it. The book reports information from a 1971 interview survey of 279 mothers with a recently born infant, residing in or around Lexington, Kentucky. The text is essentially 68 tables strung together by a narrative that reads alternately like an undergraduate lecture or a sermon. The seven chapters are roughly divided into sections on methodology, classical social descriptors of the families, measures of maternal attitudes toward the event and the impact of the pregnancy on the family, descriptions of early infant care by the mother and father, and finally health care resources for the infant and the family. The sociometric approach engenders a profusion of numbers and a complete absence of any human feeling for the families involved. The few verbatim quotes have none of the good humored glimpses which make the Newson's Infant Care in an Urban Corn-
829
munity so perceptive and meaningful. Perhaps this is the nature of Kentucky families. I doubt it; I think it reflects the nature of the survey and the prolonged genesis of the publication. The book is also flawed from the viewpoint of its science. There are multiple examples. The author for example in Chapter 2 justifies the interview process extensively but gives no information on the method for selection of the "10% representative sample", nor any specifics of the interview questionnaire, nor the method used for classifying or coding the responses for analysis. He indicates that the interviewers (medica! students) were "tra!ned" but g!ves no data on interviewer reliability or validation of the information obtained. Data on fathers' activities were obtained from mothers without confirming the information with the fathers themselves or apparently considering the potential bias involved. Questions concerning the provision of health care were evaluated without talking to the health care providers. Comments are made comparing generalist versus specialist care without measures of the quality of the health care rendered by one or the other. Considerable attention is given to indirect surmise as to why families choose one type of health care provider over another, but no one ever asked the families either directly or indirectly. Hypotheses are suggested on matters such as mothers' attitudes to contraceptives or going back to work after having their child, without apparently actual inquiry on the mothers' opinions. The data analysis also leaves much to be desired. Statistical analyses are strewn about in profusion without specification of the methods used, the applicability of the statistic to the data, or the effect of the numbers of comparisons. Means and standard deviations are calculated for data that are clearly not "normal" in distribution so that standard deviations often approach the value of the mean--suggesting absurd "negative" values for the bottom end of the curve. Such calculations may sometimes be of value, they are more often misleading and inappropriate; graphic presentation of frequency distributions and the use of observed percentiles would have been far more useful, more understandable and of more value for comparison between groups. Statements are made which imply meaningful differences where statistical analysis shows "no significance", reflecting at best a cavalier disregard for the purpose and meaning of such analysis. This will suffice, I hope, to indicate why I cannot recommend this book.
Department of Pediatrics University of Washington School of Medicine Seattle, Washington, U.S.A.
RALPH J. WEDGWOOD
Infants, Mothers, and Doctors, by EUGENEB. GALLAGHER. Heath, Lexington, MA, 1978. 210 pp. $18.00 VIEW 2: FROM THE SOCIAL SCIENTIST
Infants, Mothers, and Doctors is a sociological study of expectant mothers and their infants in Lexington, Kentucky. The study has four foci: health care, particularly health care of the expectant mother and infant; the care of young infants; family roles, particularly those of mother, father and infant; and the community context of health care, infant care and the family. The author points out that the intent of the study is to provide a contemporary view of health and infant care in smaller metropolitan areas of the U.S. and to provide "social documentation of the way we live". The subject of Dr Gallagher's book is timely and significant. His presentation of material, however, lacks clarity of purpose and a common and integrating theme. Often
Dept. of Socio-Medical Sciences and Community Medicine Boston University School of Medicine MA, U.S.A.
GEORGE J. ANNAS
Infants, Mothers and Doctors, by EUGENE B. GALLAGHER. Heath, Lexington, MA, 1978. 220 pp. $18.00 VIEW 1: FROM THE PHYSICIAN The transformation of the general practitioner from a sentimental, historical fiction to an active agent for social change has rejuvenated the popularity of family practice and brought in its wake a demand for information about families--their health care and their needs. Thus reviewing Eugene B. Gallagher's book with its catchy title, Infants, Mothers and Doctors, seemed a worthwhile task. I looked forward to learning something to supplement my Anglophilic reliance on the Opie's, the Newson's, and Pinchbeck and Hewitt. I was disappointed. The book is tedious and does little more than enumerate common knowledge. The writing is tendentious and humorless. At this point any wise reader will quit reading this review to save further waste of time. I, having read the book--all 200 lackluster pages of it--must earn my r eviewer's copy by saying what the book is about and why I didn't like it. The book reports information from a 1971 interview survey of 279 mothers with a recently born infant, residing in or around Lexington, Kentucky. The text is essentially 68 tables strung together by a narrative that reads alternately like an undergraduate lecture or a sermon. The seven chapters are roughly divided into sections on methodology, classical social descriptors of the families, measures of maternal attitudes toward the event and the impact of the pregnancy on the family, descriptions of early infant care by the mother and father, and finally health care resources for the infant and the family. The sociometric approach engenders a profusion of numbers and a complete absence of any human feeling for the families involved. The few verbatim quotes have none of the good humored glimpses which make the Newson's Infant Care in an Urban Corn-
829
munity so perceptive and meaningful. Perhaps this is the nature of Kentucky families. I doubt it; I think it reflects the nature of the survey and the prolonged genesis of the publication. The book is also flawed from the viewpoint of its science. There are multiple examples. The author for example in Chapter 2 justifies the interview process extensively but gives no information on the method for selection of the "10% representative sample", nor any specifics of the interview questionnaire, nor the method used for classifying or coding the responses for analysis. He indicates that the interviewers (medica! students) were "tra!ned" but g!ves no data on interviewer reliability or validation of the information obtained. Data on fathers' activities were obtained from mothers without confirming the information with the fathers themselves or apparently considering the potential bias involved. Questions concerning the provision of health care were evaluated without talking to the health care providers. Comments are made comparing generalist versus specialist care without measures of the quality of the health care rendered by one or the other. Considerable attention is given to indirect surmise as to why families choose one type of health care provider over another, but no one ever asked the families either directly or indirectly. Hypotheses are suggested on matters such as mothers' attitudes to contraceptives or going back to work after having their child, without apparently actual inquiry on the mothers' opinions. The data analysis also leaves much to be desired. Statistical analyses are strewn about in profusion without specification of the methods used, the applicability of the statistic to the data, or the effect of the numbers of comparisons. Means and standard deviations are calculated for data that are clearly not "normal" in distribution so that standard deviations often approach the value of the mean--suggesting absurd "negative" values for the bottom end of the curve. Such calculations may sometimes be of value, they are more often misleading and inappropriate; graphic presentation of frequency distributions and the use of observed percentiles would have been far more useful, more understandable and of more value for comparison between groups. Statements are made which imply meaningful differences where statistical analysis shows "no significance", reflecting at best a cavalier disregard for the purpose and meaning of such analysis. This will suffice, I hope, to indicate why I cannot recommend this book.
Department of Pediatrics University of Washington School of Medicine Seattle, Washington, U.S.A.
RALPH J. WEDGWOOD
Infants, Mothers, and Doctors, by EUGENEB. GALLAGHER. Heath, Lexington, MA, 1978. 210 pp. $18.00 VIEW 2: FROM THE SOCIAL SCIENTIST
Infants, Mothers, and Doctors is a sociological study of expectant mothers and their infants in Lexington, Kentucky. The study has four foci: health care, particularly health care of the expectant mother and infant; the care of young infants; family roles, particularly those of mother, father and infant; and the community context of health care, infant care and the family. The author points out that the intent of the study is to provide a contemporary view of health and infant care in smaller metropolitan areas of the U.S. and to provide "social documentation of the way we live". The subject of Dr Gallagher's book is timely and significant. His presentation of material, however, lacks clarity of purpose and a common and integrating theme. Often