- Email: [email protected]
The cultural geography of health care
1580 environment issue as another factor that people’s reproductive rights. He concludes:
Book Reviews infringes
on
If the rights of individual women to freedom of choice are to be superseded not only by the supposed national interest, but also by the rights of the ‘planet’ or the ‘biotic community’, then the outlook for reproductive freedom is bleak indeed (p. 44). “Trust the parents” is the title of the final chapter of the book. In this chapter Whelan argues that people should decide when and how many children they want. He cites the considerable body of anthropological studies that show how people have always regulated their fertility. using a variety of traditional means such as breastfeeding and post-partum abstinence. Parents take into account a variety of factors when deciding how many children they wish, including their own living conditions, and the educational and employment opportunities for their offspring. He raises the question: “how can a politician or U.N. official believe that he (or she) comprehends the peasant woman’s needs better than she does herself?” (p. 47). He ends his book with a recommendatton that in the public discussion of population policies policy makers observe a more exact use of terminology. The term family planning should not be used to describe schemes which are designed to pressure people into having fewer children than they would wish to have. This clarity in terminology. is the least that Western governments can do, if they arc determined to spend their taxpayers’ money to finance programs that do not respect the freedom of choice of individual couples. The aim of the book is to make policy makers and politicians aware of the infringements of human rights 01 couples that occur in family planning program. By writing a short and very readable book, and by putting forward examples of family planning programs that aim at reducing fertility levels of the population, and do not respect people’s reproductive rights, this aim is achieved. However, the discussion on the influence of population control ideologies on family planning implementation would have been more interesting if a differentiation had been made between types of family planning programs involved. At the national level. in many countries, a diversity of family planning programs exist: small private initiaives that take women’s autonomy as a starting point, bigger government programs that provide contraceptives within the context of mother and child care (MCH). and large-scale government programs that aim at reducing fertility-levels in a target-oriented manner. Where the latter are likely to infringe on people’s human rights, the question is if this is
The Cultural Geography of Health Care, by WILLSEKTM. GESLER. University of Pittsburgh Press, Pittsburgh. 1991. iv and 245 pp. maps, diags, tables. notes. and index, $39.95 cloth. ISBN O-8229-3664-X. This book is an unusual and a most welcome addition to the corpus of both cultural and medical geography. Growing out of Wilbert Gesler’s extensive academic and field experience, in cultural geography and the geography of health care delivery, it brings to light many conjunctions where both specialties can experience synergism. This is not just a textbook for some narrowly defined geographical specialty, but a useful guide for thinking about health and culture in the spatially differentiated and dynamic contexts of this diad throughout the world. This is not a book on medical geography but tries to show how a culturally informed and
the case in the situations in which family planning is integrated in mother and child care. It can be questioned, further, if people who work within the population establishment in international development agencies and the United Nations will be convinced by the book that population control and family planning should be treated as two different issues. In these agencies, population growth continues to be seen as an important factor in the vicious cycle of underdevelopment, poverty and environmental degradation. Whelan does not explain why aiming at reducing population growth by means of family planning is not the best way to achieve development, other than citing in passing literature that “questions the supposed link between population growth and poverty” (p. I). Finally, it is important to note that in agencies such as the United Nations Fund for Population (UNFPA) and the Population Council, it is increasingly recognized that for family planning programs to be effective women’s status has to be improved, and the quality of family planning and reproductive health care services addressed [4]. This shift in emphasis from coverage and targets to quality of care and women’s status, implies a shift in orientation of the people workmg in the agencies. The shift, moreover, does not occur in a vacuum. It is influenced by powerful lobby groups such as the International Women’s Health Coalition. and the Women’s Global Network on Reproductive Rights, that criticize the target-orientation of many family planning program, and call for more need-oriented approaches. In contrast to what Whelan suggest. I believe that in the field of population control and family planning more is changing than the rhetoric. ANITA P. HAKDON
REFERENCES Warwick D. P. Bitter Pil1.s: Population Policies md rhrir Inrplemm/u~ion in Eigk/ Countrirs. Cambridge University Press. Cambridge, 1982. Hartmann B. Rrproduc~rirv F3ghr.c and Wrongs ----the t~lohal Polilics of Populfltion Conlrol and Conrrucqliw Choice. Harper and Row. New York. 1987. Germain A. and Ordway J. Populution Control and Women’.s Hralth: Balancing the Scales. International Women’s Health Coalition, New York, 1989. Bruce J. Fundamental elements of the quahty of care: a simple framework. S/trd. Fani. Planning 21, (2). 61-91, 1990.
contextually aware health care system can be more responsive to the community it tries to serve. It is one of the author’s main aims to reduce the intentionperception gap between the health care providers and the “beneficiaries”. The book is divided into I2 chapters. Each chapter (excluding introduction and summary)+s organized under a major cultural geography concept or theme--cultural systems, cultural regions. cultural evolution. cultural diffusion, folk and popular culture, language, social space, place and landscape, and cultural materialism. Gesler employs cultural geography’s main concepts as tools of thought, and demonstrates their applicability to and utility in medical geography. These concepts do not remain mere abstractions but become central to the book’s organization. Gesler utilizes not only the time-honored concepts of cultural geography such as cultural systems. cultural diffusion, and
Book Reviews
1581
cultural regions, but incorporates the themes and concepts of ‘new’ cultural geography in the wake of post-Sauerian revival and transformation. Gesler has made good use of the contemporary methodological critique of older historicalcultural geography by humanistic, symbolic, and materialistic social theory, which has added sophistication to our understanding of the varied health care contexts. Gesler employs a uniform template for presenting his material in each chapter. He first explains each cultural concept, and its nuances, in a simple, non-jargonistic, but pedagogically effective manner. He then proceeds to examine ways in which applications of that concept help the reader understand medical geography issues within different cultural contexts. The examples are selected from author’s own first hand knowledge of medical geography issues in many parts of the world, and from a wide array of literature, both geography and other social sciences, related to health issues. Some examples are more detailed than others, but rarely is a concept left dangling for want of an appropriate example. At the end of each chapter Gesler pulls together the main ideas in the form of a chapter summary, and points out fruitful areas for further research. The summaries will be helpful to readers. especially in light of the numerous examples he gives. In addition, Gesler alerts the reader, at the end of each chapter, to the contents of the next chapter-a thoughtful pedagogic device. A major strength of The Cultural Geography of Health Care lies in the author’s ability to identify and to effectively employ the concepts of traditional and rapidly transforming cultural geography-informed by social theory. Gesler does not seem to promote these concepts in a partisan fashion, as some proponents of the ‘new’ cultural geography are wont to do, but rather brings out the relevance and utility of each concept in better revealing the variety of cultural contexts of health care in the hope that health care may be delivered more effectively. Gesler’s book does not try to demolish tradition cultural geography in order to establish the primacy of new cultural geography with its social theory orientation. Instead, his approach is eclectic. Gesler has argued that the “Biomedical System” in spite of its explicitly hegemonic character is, after all, one of the systems of healing rather than the system by whose premises all others must always be measured. He is able to successfully place the technologically and politically dominant biomedical system alongside the “traditional” systems of healing. One may, however, disagree with Gesler’s use of the word “traditional”, instead of the more neutral and increasingly more acceptable term “alternative”, to describe other systems of healing, especially in view of his emphasis (in chap. 8) on the significance of semantic networks in the health care context. By de-mystifying the healing role of the biomedical system, however, Gesler broadens the context of health care, and is thus able to present health seekers not just as sick people but as reasonable decision-makers within their special socio-cultural environment. Gesler has innovatively used “Language” (chap. 8) not just as a spatial attribute, but as a versatile cultural tool by which the health care as a negotiated reality is more fully implemented. His Quechua example (p. 106) of the adoption of oral rehydration techniques, although adduced as an example of cultural diffusion in chap. 6, also shows how powerful a tool
language is in the health care context; the use of Quechua language by the health establishment facilitates innovation diffusion, but also bridges the social gap between the health bureaucracy and the native doctors. This example could equally fit under his discussion of language in chap. 8. Gesler has used this and many similar examples to illustrate the realities of health care in the cultural context. Language (in chap. 8) is utilized as a taxonomic device for cultural categories of health and disease, as a metaphor, a model, and as semantic networks. Unfortunately, his chapter end summary, does not do justice to the richness of material he presented in the chapter itself. It is in his last three substantive chapters (chaps 9-11) that Gesler most effectively uses the concepts and formulations of the ‘new’ cultural geography. Structuralist perspective, humanism, and structuration theory respectively dominate these chapters. He examines the idea of social space by comparing health care delivery in the context of five countries, each with a distinctly different system (free enterprises, welfare state, socialist state, underdeveloped system, and a transitional system). Structuralist analysis of these diverse countries clearly shows how marginality of indigenous healing systems, and other non-biomedical systems was brought about. The concepts of place and landscape are discussed in the framework of humanistic tradition of geography, in which meaning and understanding of the nature of experience related to health care dominate the discussion. Gesler has rightly pointed out the dearth of medical geography studies using the humanistic perspective in identifying and describing the “therapeutic landscape”. Indeed the example of Freetown (Sierra Leone) Hill Station, could be multiplied by taking instances in other parts of the former British colonial empire. Employing Structuration theory as the vehicle (chap. 1I), Gesler attempts to show how “agency and structure interact but finds it difficult to always draw the in practice”, distinction between agency and structure. Nevertheless, he hopes that humanism and structuralism when blended together, may shed more light on the cultural context of health care systems. Gesler strongly argues in favor of ‘&acombination of humanist and structuralist thinking” but cautions about an uncritical application of structurationist theory. The format and organization of The Cultural Geography of Health Care, its use of numerous examples, its non-jargonistic arguments backed up by a wealth of references, and its relatively informal first person writing style, should make this work a popular textbook for students of both cultural and medical geography. One could argue that fewer, examples would have permitted Gesler to more fully develop his explanation of the concepts he has employed. On the other hand, this very aspect of the book might induce the teachers to explain the concepts further without undue repetition of the text in the classroom. Well documented and well organized, encompassing the concepts of both ‘new’ and traditional cultural geography, The Cultural Geography of Health Care could be a required reading for courses on medical geography and cultural geography alike.
The Initiation of National Nutrition Policies: A Comparative Study of Norway and Greece, by ELISABETHELSING. STYX Publications, Groningen, 1990. 206pp., Dutch Hfl. 96.00.
researcher. She had been awarded a grant to investigate the factors which influence that nation’s dietary habits: whether these be dominantly centrally planned or individually economically determined or by perceived nutritional value or culturally or by individual taste. The radio interviewer was clearly surprised that the topic warranted
During the month of August 1992 during a visit to England, I heard by chance a radio interview with a British MRC
Department of Geograph? Kent State Unioersit) Kenl, OH 44242, lJ.S.A
SURINDER M. BHARDWAJ
Book Reviews infringes
on
If the rights of individual women to freedom of choice are to be superseded not only by the supposed national interest, but also by the rights of the ‘planet’ or the ‘biotic community’, then the outlook for reproductive freedom is bleak indeed (p. 44). “Trust the parents” is the title of the final chapter of the book. In this chapter Whelan argues that people should decide when and how many children they want. He cites the considerable body of anthropological studies that show how people have always regulated their fertility. using a variety of traditional means such as breastfeeding and post-partum abstinence. Parents take into account a variety of factors when deciding how many children they wish, including their own living conditions, and the educational and employment opportunities for their offspring. He raises the question: “how can a politician or U.N. official believe that he (or she) comprehends the peasant woman’s needs better than she does herself?” (p. 47). He ends his book with a recommendatton that in the public discussion of population policies policy makers observe a more exact use of terminology. The term family planning should not be used to describe schemes which are designed to pressure people into having fewer children than they would wish to have. This clarity in terminology. is the least that Western governments can do, if they arc determined to spend their taxpayers’ money to finance programs that do not respect the freedom of choice of individual couples. The aim of the book is to make policy makers and politicians aware of the infringements of human rights 01 couples that occur in family planning program. By writing a short and very readable book, and by putting forward examples of family planning programs that aim at reducing fertility levels of the population, and do not respect people’s reproductive rights, this aim is achieved. However, the discussion on the influence of population control ideologies on family planning implementation would have been more interesting if a differentiation had been made between types of family planning programs involved. At the national level. in many countries, a diversity of family planning programs exist: small private initiaives that take women’s autonomy as a starting point, bigger government programs that provide contraceptives within the context of mother and child care (MCH). and large-scale government programs that aim at reducing fertility-levels in a target-oriented manner. Where the latter are likely to infringe on people’s human rights, the question is if this is
The Cultural Geography of Health Care, by WILLSEKTM. GESLER. University of Pittsburgh Press, Pittsburgh. 1991. iv and 245 pp. maps, diags, tables. notes. and index, $39.95 cloth. ISBN O-8229-3664-X. This book is an unusual and a most welcome addition to the corpus of both cultural and medical geography. Growing out of Wilbert Gesler’s extensive academic and field experience, in cultural geography and the geography of health care delivery, it brings to light many conjunctions where both specialties can experience synergism. This is not just a textbook for some narrowly defined geographical specialty, but a useful guide for thinking about health and culture in the spatially differentiated and dynamic contexts of this diad throughout the world. This is not a book on medical geography but tries to show how a culturally informed and
the case in the situations in which family planning is integrated in mother and child care. It can be questioned, further, if people who work within the population establishment in international development agencies and the United Nations will be convinced by the book that population control and family planning should be treated as two different issues. In these agencies, population growth continues to be seen as an important factor in the vicious cycle of underdevelopment, poverty and environmental degradation. Whelan does not explain why aiming at reducing population growth by means of family planning is not the best way to achieve development, other than citing in passing literature that “questions the supposed link between population growth and poverty” (p. I). Finally, it is important to note that in agencies such as the United Nations Fund for Population (UNFPA) and the Population Council, it is increasingly recognized that for family planning programs to be effective women’s status has to be improved, and the quality of family planning and reproductive health care services addressed [4]. This shift in emphasis from coverage and targets to quality of care and women’s status, implies a shift in orientation of the people workmg in the agencies. The shift, moreover, does not occur in a vacuum. It is influenced by powerful lobby groups such as the International Women’s Health Coalition. and the Women’s Global Network on Reproductive Rights, that criticize the target-orientation of many family planning program, and call for more need-oriented approaches. In contrast to what Whelan suggest. I believe that in the field of population control and family planning more is changing than the rhetoric. ANITA P. HAKDON
REFERENCES Warwick D. P. Bitter Pil1.s: Population Policies md rhrir Inrplemm/u~ion in Eigk/ Countrirs. Cambridge University Press. Cambridge, 1982. Hartmann B. Rrproduc~rirv F3ghr.c and Wrongs ----the t~lohal Polilics of Populfltion Conlrol and Conrrucqliw Choice. Harper and Row. New York. 1987. Germain A. and Ordway J. Populution Control and Women’.s Hralth: Balancing the Scales. International Women’s Health Coalition, New York, 1989. Bruce J. Fundamental elements of the quahty of care: a simple framework. S/trd. Fani. Planning 21, (2). 61-91, 1990.
contextually aware health care system can be more responsive to the community it tries to serve. It is one of the author’s main aims to reduce the intentionperception gap between the health care providers and the “beneficiaries”. The book is divided into I2 chapters. Each chapter (excluding introduction and summary)+s organized under a major cultural geography concept or theme--cultural systems, cultural regions. cultural evolution. cultural diffusion, folk and popular culture, language, social space, place and landscape, and cultural materialism. Gesler employs cultural geography’s main concepts as tools of thought, and demonstrates their applicability to and utility in medical geography. These concepts do not remain mere abstractions but become central to the book’s organization. Gesler utilizes not only the time-honored concepts of cultural geography such as cultural systems. cultural diffusion, and
Book Reviews
1581
cultural regions, but incorporates the themes and concepts of ‘new’ cultural geography in the wake of post-Sauerian revival and transformation. Gesler has made good use of the contemporary methodological critique of older historicalcultural geography by humanistic, symbolic, and materialistic social theory, which has added sophistication to our understanding of the varied health care contexts. Gesler employs a uniform template for presenting his material in each chapter. He first explains each cultural concept, and its nuances, in a simple, non-jargonistic, but pedagogically effective manner. He then proceeds to examine ways in which applications of that concept help the reader understand medical geography issues within different cultural contexts. The examples are selected from author’s own first hand knowledge of medical geography issues in many parts of the world, and from a wide array of literature, both geography and other social sciences, related to health issues. Some examples are more detailed than others, but rarely is a concept left dangling for want of an appropriate example. At the end of each chapter Gesler pulls together the main ideas in the form of a chapter summary, and points out fruitful areas for further research. The summaries will be helpful to readers. especially in light of the numerous examples he gives. In addition, Gesler alerts the reader, at the end of each chapter, to the contents of the next chapter-a thoughtful pedagogic device. A major strength of The Cultural Geography of Health Care lies in the author’s ability to identify and to effectively employ the concepts of traditional and rapidly transforming cultural geography-informed by social theory. Gesler does not seem to promote these concepts in a partisan fashion, as some proponents of the ‘new’ cultural geography are wont to do, but rather brings out the relevance and utility of each concept in better revealing the variety of cultural contexts of health care in the hope that health care may be delivered more effectively. Gesler’s book does not try to demolish tradition cultural geography in order to establish the primacy of new cultural geography with its social theory orientation. Instead, his approach is eclectic. Gesler has argued that the “Biomedical System” in spite of its explicitly hegemonic character is, after all, one of the systems of healing rather than the system by whose premises all others must always be measured. He is able to successfully place the technologically and politically dominant biomedical system alongside the “traditional” systems of healing. One may, however, disagree with Gesler’s use of the word “traditional”, instead of the more neutral and increasingly more acceptable term “alternative”, to describe other systems of healing, especially in view of his emphasis (in chap. 8) on the significance of semantic networks in the health care context. By de-mystifying the healing role of the biomedical system, however, Gesler broadens the context of health care, and is thus able to present health seekers not just as sick people but as reasonable decision-makers within their special socio-cultural environment. Gesler has innovatively used “Language” (chap. 8) not just as a spatial attribute, but as a versatile cultural tool by which the health care as a negotiated reality is more fully implemented. His Quechua example (p. 106) of the adoption of oral rehydration techniques, although adduced as an example of cultural diffusion in chap. 6, also shows how powerful a tool
language is in the health care context; the use of Quechua language by the health establishment facilitates innovation diffusion, but also bridges the social gap between the health bureaucracy and the native doctors. This example could equally fit under his discussion of language in chap. 8. Gesler has used this and many similar examples to illustrate the realities of health care in the cultural context. Language (in chap. 8) is utilized as a taxonomic device for cultural categories of health and disease, as a metaphor, a model, and as semantic networks. Unfortunately, his chapter end summary, does not do justice to the richness of material he presented in the chapter itself. It is in his last three substantive chapters (chaps 9-11) that Gesler most effectively uses the concepts and formulations of the ‘new’ cultural geography. Structuralist perspective, humanism, and structuration theory respectively dominate these chapters. He examines the idea of social space by comparing health care delivery in the context of five countries, each with a distinctly different system (free enterprises, welfare state, socialist state, underdeveloped system, and a transitional system). Structuralist analysis of these diverse countries clearly shows how marginality of indigenous healing systems, and other non-biomedical systems was brought about. The concepts of place and landscape are discussed in the framework of humanistic tradition of geography, in which meaning and understanding of the nature of experience related to health care dominate the discussion. Gesler has rightly pointed out the dearth of medical geography studies using the humanistic perspective in identifying and describing the “therapeutic landscape”. Indeed the example of Freetown (Sierra Leone) Hill Station, could be multiplied by taking instances in other parts of the former British colonial empire. Employing Structuration theory as the vehicle (chap. 1I), Gesler attempts to show how “agency and structure interact but finds it difficult to always draw the in practice”, distinction between agency and structure. Nevertheless, he hopes that humanism and structuralism when blended together, may shed more light on the cultural context of health care systems. Gesler strongly argues in favor of ‘&acombination of humanist and structuralist thinking” but cautions about an uncritical application of structurationist theory. The format and organization of The Cultural Geography of Health Care, its use of numerous examples, its non-jargonistic arguments backed up by a wealth of references, and its relatively informal first person writing style, should make this work a popular textbook for students of both cultural and medical geography. One could argue that fewer, examples would have permitted Gesler to more fully develop his explanation of the concepts he has employed. On the other hand, this very aspect of the book might induce the teachers to explain the concepts further without undue repetition of the text in the classroom. Well documented and well organized, encompassing the concepts of both ‘new’ and traditional cultural geography, The Cultural Geography of Health Care could be a required reading for courses on medical geography and cultural geography alike.
The Initiation of National Nutrition Policies: A Comparative Study of Norway and Greece, by ELISABETHELSING. STYX Publications, Groningen, 1990. 206pp., Dutch Hfl. 96.00.
researcher. She had been awarded a grant to investigate the factors which influence that nation’s dietary habits: whether these be dominantly centrally planned or individually economically determined or by perceived nutritional value or culturally or by individual taste. The radio interviewer was clearly surprised that the topic warranted
During the month of August 1992 during a visit to England, I heard by chance a radio interview with a British MRC
Department of Geograph? Kent State Unioersit) Kenl, OH 44242, lJ.S.A
SURINDER M. BHARDWAJ