Medical anthropology

Medical anthropology

778 Book reviews A Right to Health: The Problem of Access to primary Medical Care, by CHARLESE. LEWIS RASHI FEIN and DAVID MECHANIC.John Wiley, N.Y...

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Book reviews

A Right to Health: The Problem of Access to primary Medical Care, by CHARLESE. LEWIS RASHI FEIN and DAVID MECHANIC.John Wiley, N.Y. 1976. 367 pp. 517.95 This book analyzes the impact on access to care of eleven federal health programs of the 1960s and 1970s in the U.S.A. and discusses some long-range options for increasing access. The book also provides some insight into the disincentives against medical students and junior faculty choosing careers in primary care practice or education. However, a basic myth underlying the entire book must be questioned, and the marked contrasts of focus from section to section are significant problems for the reader. The title and the content of the book perpetuate the myth that personal health services are a major factor in the health status of populations. The whole point of the book seems to be that, if we could create the best possible access to medical care, we would achieve the state of being healthy. This state is even referred to as a “right” in the title. Thomas McKeown in Population Studies (Vol. 16, 1962, pp. 94-122 and Vol. 29, 1975, pp. 391-422) has been unable to show that specific medical therapy (except smallpox vaccination) at&&d the long term decline in mortality of the nineteenth century. In the 20th century, McKeown showed that improved nutrition accounted for 50% of the decline in mortality, better hygiene for 170/, and specific therapies and immunizations for only loo/, of the decline in mortality. John B. McKinlay and Sonja M. M&inlay of the Boston University, School of Medicine, have more thoroughly reviewed this subject for the U.S.A. in their paper ‘The Questionable ElIect of Medical Measures on the Decline of Mortality” than I can possibly do here. Suffice it to say that simply equating access to personal health services with improved health status is a myth against which there is growing evidence. Lifestyle choices are probably far more important determinants of health status than is access to personal medical care services. Another problem with this book is that the degree of focus varies widely from section to section. The book’s historical section is tightly focused on the individual development of each of eleven programs: loan forgiveness, rural preceptorships, family practice, physician supply, new health practitioners, the health service corps, Medicare, Medicaid, OEO health centres, Children and Youth and Health Maintenance Programs. The nature of each program’s intervention, its sources, evidence of effectiveness, costs, secondary effects, and impact on access to primary care are discussed. Part III of the book presents broadly focused options for increasing access to personal health services. One option would seek to change the labor market for health care providers by matching the specialty distribution of physician training slots more closely to the known requirements for services by defined populations. Prospective national budgeting of expenditures is advocated for all aspects of care including physician services. National health insurance is discussed as necessary to increase financial access to care but requires “ex ante” (prospective) budgeting for health care to keep the system affordable in the future. Financing arrangements are advocated which would reallocate resources to primary care from hospital and specialist care. The book’s last section concerns short-range options. The most important part of this is the discussion of medical school priorities in primary care. The “step-child” relationship of primary care to medical schools and their faculties is described. Traditional faculties believe in and reward students and junior faculty for their scholarly writing, their depth, their full-time institutional commitment, and their hospital-based teaching. Contrast those priorities with those of primary care faculty who emphasize their service in patient care, their breadth more than depth, their part-

time roles in both academia and front-line medicine, and their base in office-practice and home. The latter group faculty have great difficulty finding reward or career in the shadow of the traditional faculty. The book advocates support of schools which desire increased emphasis on primary care as a “short-term option”. However, it is not a short-term option at all because the vast majority of medical schools which express more primary care interest actually have existing traditional faculties with attitudes significantly opposed to the basic characteristics of primary care faculties. The traditional faculty is often so uncomfortable with the priorities of primary care that they have great difficulty in even achieving peaceful coexistence. This conflict of basic academic values between traditional medical faculties and primary care faculty is underestimated in this book. The following critical questions about primary care education are not dealt with: 1. Should we get primary care education out of medical schools? 2. Should primary care be taught in a new 20th century apprenticeship? 3. Should primary care be learned after hospital care, such that continuing medical education is the proper site for primary care education? 4. Should parent universities of medical schools create new Schools of Primary Care Medicine which could appoint and reward their own faculties for the unique characteristics necessary to their own educational work? Some similar rationale was involved in creating public health faculties separate from medical faculties. In summary, A Right to Health... is of interest for its program analysis and its broadly focused options for improving access to care, but the misleading myth of the absolute importance of personal health services to health is perpetuated. RICHARDW. D~DDS Department of Epidemiology and Ofice of Extramural Health Programs Harvard School of Public Health Boston, MA, U.S.A.

Medical Anthropology, edited by FRANCISS. GROLLIGand HAROLDB. HALEY. Mouton, The Hague 1976. 485 pp. 627.50. This book collects 27 papers written for a medical anthropology section of the Ninth International Congress of Anthropological and Ethnological Sciences, held in Chicago during 1973. The authors represent a variety of scholarly backgrounds (anthropology, medicine, human biology, sociology, archaeology, social work, history) and come from Africa, Europe, South Asia, and North and South America. If, as one famous anthropologist has suggested, the goals of the Congress were to bring together a widely representative group of scholars and scientists to exchange insights and advance the frontiers of anthropology and its sub-disciplines, this volume seems to have succeeded mainly on the first count. The editors write in their preface that they “...consciously refrained from extensive “revisions” of the manuscripts and transcriptions because we believe that no good purpose can be served by straining the thoughts of the whole world through a Western (ethnocentric!) screen: we respect the individuality of our colleagues and their scholarly contributions to the volume.” Readers of this book are likely to be less tolerant of its shortcomings. Indeed, it is ironic that some of the articles that need straining most are the products of Western natives, and that the “originality” of several contributions reflects more than

Book reviews

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tions in this volume are Peter Maguire’s and Derek Rutter’s interviewing model and training procedures aimed at improving medical students’ interviewing skills and Martin Fishbein’s theoretical model for a better understanding of communication as & process. Indeed, the problem of communication between patients and doctors has been widely recognized and discussed by social scientists and physicians. However, no systematic research on conversation for the purpose of understanding and teaching the uses and functions of language in medicine has been carried out. Although everyone knows hew to use language, most of us do not have an understanding of its properties and functions, and therefore, without formal training are not equipped to use it c5ectively in a professional setting. It is our belief that in medicine, the study of language use is fundamental to understanding the nature of the relationship between doctor and patient, doctor and doctor, or patient and nurse. Such an understanding would help reveal the underlying beliefs and values speakers have about disease, and their attitudes towards the body, sickness, health and death. It also has important pragmatic implications. If one wants to change the doctor’s focus from an intereat in disease to an increased concern for the patient with the disease, changing the language of the physician is one way towards that goal. But if language use is to be changed, language must be understood in depth for what it does and can do in the care of the patient. Not only must the uses and functions of language in medicine be investigated but they must be taught to medical students as a discipline like physical diagnosis. At present, training in communication is con&d to courses in medical interviewing which usually consist in demonstrating good or bad ways of asking questions and rarely deal with subjects like explaining, reassuring, convincing, or instructALLANYOUNG ing. These courses also fail to emphasize the difference Department of Anthropology Case Western Reserue University between hearing and interpreting what patients say, Cleveland, Ohio, between the observation and the interpretation. Clearly, U.S.A. listening to spoken language always involves interpretation, since hearing is a subjective process, but there is Commonieatiao Betweeo Doctors IUWIPatients, edited by a difference between language data, e.g. words, sentences, A. E. BENNETT.Oxford Universitv Press. London. 1976. pauses, pitch, intonation (structure) and the interpretation 134 pp. f3 net. of the meaning a speaker intends to convey (function). A trained listener is able to recognize the reasonsfor his In Communication Between Doctors and Patients, A. E. Beninterpretations of the speaker’s meaning, as well as to connett has brought together a number of essays from psysciously choose the forms which beat express what he inchiatry, medicine, and social psychology. These essays distends to convey. But training in language use requires a cuss the relationship between communication and effective body of theory and knowledge based on natural language medical practice. This review will focus on the book’s condata which has not been available to the present time. tribution to the problems of doctor-patient communicaThese are aspects of the problem which past research tion viewed from the perspective of a student of language has not dealt with squarely, some of which have bctn ackin medicine. nowledged by the authors of the book. As stated by BenThe overriding theme of the book is that failure to comnett in his postscript to the book: “we know what we municate in medicine interferes with effective medical pracwant to do but moat of us do not know, other than intuititice. While this is not new, the book’s main contribution vely, how to do it. It follows that we are unable to monitor lies in stressing the following points which seem basic to our own performance with a view to seeking improvement” the problem: (1) medical practitioners want to communi@. 129). As a result, he adds, “it is not something which cate better with their patients, but don’t know how to do can be easily taught” (p. 129). Tbcrefor~ systematic trainit; (2) medical practitioners must be. actively trained to iming and not recipes must be offered to medical practiprove communication with their patients; and (3) a theortioners as a prerequisite for any change to the present situetical framework is necessary to examine communication ation. This ooint is emphasized by Masmire and Rutter as a process but is presently lacking. @. 57) who stress the &portance -of sk&ul interviewing Marie Johnston attempts to measure patient-nurse combased on training for e5ective medical practice. They promunication by means of questionnaires, although her pose an interviewing model and 05er detailed techniques approach does not seem to adequately handle the probfor history taking aimed at eliciting precise and relevant lems or their solutions. Philip Ley reports on studies of data which are crucial if patients are to comply with advice patient dissatisfaction and noncompliance and makes a few and treatment. They also describe their training procedures helpful practical suggestions to improve this state of affairs. which include practice interviews with actual patients and Cohn Fraser proposes a framework for the analysis of faceevaluation techniques. Unfortunately, as with many other to-face interaction, and stresses that communication is a good interviewing programs, the authors fail to recognize process involving a number of elements that are “dynamic that training is needed at a much more fundamental level features which change constantly and interact in an intrithan the one they propose. cate way” (p. 14). He also makes some suggestions for Fishbein, who insightfully discusses persuasion in medireducing miscommunication. The most useful contribucine (hence, compliance), suggests that failure to succe-ssanything else their failure to set analyses and arguments within recognizably useful frames of discourse. The contributions are very uneven in length. Some are ao brief that they amount to no more than notes or programmatic statements. This is unfortunate where contributions refer to practices about which some readers would probably like to learn more ethnographic information, e.g. beliefs rationalizing the Gmani practice of packing the post-partum mother’s vagina with table salt. On the other hand, a single article on “Prehistoric pictography in North America of medical significance” takes up nearly a hundred pages, even though much of it catalogues representations whose medical significance is in fact peripheral or elusive. Readers interested in the connection between culture, society, and medicine will, however, find useful contributions analyzing the medical uses of argillaceous earth, the cultural ecology of hookworm in India, the symbolism of snakebite cures in Central America, the epidemiology of goiter in Guatemala, Amazonian spirit beliefs and medical practices, the history of coca and its place in popular medicine in Peru, cross-cultural midwifery practices, and the socio-economic characteristics of Guatemalan Indians who adopt Western medicine. But the reader who wishes to scout the frontiers of theory in medical anthropology will be disappointed. Although the concluding section does collect four short papers under the rubric “theoretical aspects”, there is little here to justify that adjective. A final note: in addition to this book, several other Congress volumes relating to medical anthropology have been, or soon will be, published (including books on mental health alcohol use, cannabis use, and policy studics) under different editorships.