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The intellectually handicapped and their families: A new Zealand survey
Book reviews
523
practice, populations served, and recruitment. Issues relating to resources and manpower planning in a primary care group practice are examined. Guidelines for estimating physician and nurse staffing requirements are described, based on their accessibility and availability and on patient care needs. Specialty to primary physician ratios are suggested, based on the Kaiser-Permanente medical care experience. Primary care is considered to be comprehensive in scope, and, therefore, should provide for the delivery of the relatively small percentage of health services that are utilized on a non-ambulatory basis. Moreover, exposure to acute care inpatient situations is regarded as an important source of professional stimulation and continuing education, and offers the primary care physician the opportunity to be introduced to new diagnostic and treatment techniaues. Useful guidelines are offered in designing _ _ a minimal data base for evaluating performance, and assess Human Values and Ethics DAVIDC. THOMASMA management decisions. The demand for services, high and rising costs, fragmenUniversity of Tennessee Center tation and lack of coordination of services, inequity in for the Health Sciences Memphis, Tenn., U.S.A. access to services, and the growing concept that health care is a right, rather than a privilege, are major forces causing changing patterns of health care. Moreover, major technological advances, the pluralistic medical economy, consumerism, and the free market ideology of the AmeriCommunity Hospitals and Primary Care, by JOHN H. BRYANT,ALLENS. GINSBERG,SETH B. GOLDSMITH,MAR- can health care system, as well as growing local, state, and federal government involvement is shaping future diGARET C. OLENDSKIand NORA PIORE. Ballinger, Camrections in primary care delivery. Dr. Bryant’s prediction bridge, Mass., 1976. 399 pp. $14.00 is that when health care is totally accepted as a right, hospitals will be regarded by government as public utilities, This book is based on a report produced by the Center and will be controlled as such. National Health Insurance for Community Health Systems of Columbia University will provide not only the impetus for regionalization of whose purpose is to evaluate, analyze, and attempt to bring primary care centers, but be a strong factor in their conabout a better understanding in the organization and delitinuing growth. He doubts, however, that the health care very of health care. system will be federally operated. The major premise of the editors is that the community This book is a useful, practical reference for hospital hospital is the logical place for coordinating the wide spectrustees, administrators, and medical staffs interested in trum of health services included in primary, secondary, and ambulatory and primary care, and a worthy text for schotertiary medical care. The community hospital is increaslars, students, and policy makers in the general. area of ingly being called upon to provide primary care services, community health serviqes. as well as the necessary leadership and direction in developing innovative ideas and implementing effective proLancaster General Hospital NIKITASJ. ZERVANOS grams. With medical accessibility to primary care due to Family and Community various demographic, social and economic shifts among Medicine Program urban and rural groups, as well as changes in reimburseLancaster, Penn., U.S.A. ment formulae, including Medicare and Medicaid payments and other third party payers, a marked increase in ambulatory visits to hospitals has occurred. The authors trace the historical attempts of the govern‘IIe IntekctuaUy Handicapped and their Families: A New ment and private interests in developing programs to solve Zealand Survey by A. A. MORRISON,D. M. G. BEA~LEY problems in primary care delivery, both in urban and rural and K. I. WILLIAMSON. The Research Foundation of the settings, including hospital-based outpatient clinics and New Zealand Society for the Intellectually Handicapped, hospital-sponsored primary care satellites. Statistical inforWellington, New Zealand, 1976. 211 pp. $7.50 mation of emergency room use for urgent and non-urgent patients, bed size, population served, bed occupancy and teaching status is provided and expanded in an extensive This book presents the findings of an ambitious survey appendix to determine how these factors influence a hospiwhich the New Zealand Society for the Intellectually tal in developing primary care programs. Handicapped carried out in order to determine the prevaFive case studies of various hospitals were reported. lence of mental handicap in their country, to investigate Although the Hunterdon experience in Flemington, New the characteristics and needs of the individuals identified Jersey, was included among these case studies; the conand to explore the impact which the handicapped have siderable role of hospitals in the new specialty of family on their families. The research was designed to provide practice was not stressed adequately. There are now over the information, on which a rational and systematic 300 residency programs and, through their family practice approach to the planning of services could be based. centers, are paving the way for innovations in hospitalThe regions of New Zealand which were surveved insponsored primary care development. With more medical clude a quarter of the country’s population and were graduates seeking family practice residencies than positions selected for their representativeness. All available official available, the authors still remain entrenched in, the belief and voluntary sources were. used to identify those people, that the long-run tendency is for medical graduates to preaged O-64 who were “unable to lead independent lives in pare for traditional specialty practice. the community because of reduced intellectual functioning In a book of this type with 19 different authors and and impaired social adaptation” (p. 11). The parents, or 13 chapters covering overlapping issues, some redundancy parent substitutes, of nearly 90% of the sample were interis inevitable, especially on such subjects as organizational viewed concerning the handicapped individuals’ abilities, behaviour and requirements for daily care. They were and fiscal planning, health manpower, grouping of medical
cations, but of rational control over directions. We have little freedom left about applying medical technology, or medical systems. Our freedom must be exercised in gaining control of the directions of our technology. Consequently, biomedical ethical questions and theories must shift from personal and social to technological. What directions should our technology and medical systems take toward bringing about the proper ends of a good human life? Hence, I must agree with the map presented by Jongen and Helligers, a map of still uncharted ethical principles devoted to the common good. This book is a first step in that direction. It should be required reading for all students of health care, and for all interested in biomedical ethics. An excellent index enhances the strncture of the book, while the small print hinders comfortable reading of the more difficult passages.
524
Book reviews
asked to give details of the composition and financial circumstances of the family, and to describe what effect the handicapped person had on the relationships of the other family members. Finally they were questioned about the outside help, facilities or services which they used, those which they would like to use if they were more readily available, and those which they expected to need in the future. This report provides comprehensive and dispassionate information on all these topics, in a manner which is entirely suitable for the purpose for which it is designed. However the first part of the book, in particular, makes somewhat dry reading for anyone with limited knowledge of New Zealand. There is little attempt to interpret or discuss findings, which is frustrating for any reader who can think of a number of alternative explanations. For example, changes in the distribution of prevalence and severity with age in adults are interpreted as resulting from differential death rates. The possibility that any individual may become progressively more able to integrate himself into the community is not considered. The large number of tables describing differences between the Maori and European populatrons are also of limited significance to the reader with little knowledge of the extent of social, economic or even geographic integration of the races. More generally there is a need for greater discussion of the ways in which the definition of mental handicap which is used, together with the method of identifying the sample, might influence the findings. The possibility of differences in identification rates is at least worthy of consideration when interpreting the similarity between the distributions of severity of handicap in upper and lower social and economic status groups. The greater incidence of mild subnormality among the lower status groups in a variety of countries is of course well documented. The book does, however, provide an extremely valuable store of information and its faults are mainly ones of’omission. The criticisms given here are those which an academic audience might make, but that is not the audience for which the book is primarily intended. MRC Medical Sociology Cinit Institute of Medical Sociology Westburn Road Aberdeen, Scotland
FIONA WILSON
Medicine, edited by ROBERT Springer, New York, 1974. 369 pp. $13.50
The Challenges of Community L. KANE.
The Challenges of Community Medicine impresses the reviewer as being a book in search of an audience. Although billed by its publisher as “providing for the student a comprehensive, straightforward text”, student is not further defined. The book is an interesting compendium of essays, which, with two exceptions, are all original contributions. In the first chapter, “Community Medicine: What’s In A Name?“, written by Kane himself, the author states his preferred definition as being that of Tapp and Deuschele: “Community medicine is the academic discipline that deals with the identification and solution of the health problems of communities or human population groups.” T’he rationale stated for this nreference is that it “allows for flexibility and scope in b&h teaching and research”. That chapter and several others are addressed primarily to medical students, thereby allowing one to assume that they are the audience to whom the book is addressed. If so, this is far from a perfect introductory text, at least in this reviewer’s eyes. We like to think of an introductory survey course in a synthetic discipline, such as community health, as being somewhat of a smorgasbord which allows
the learner to sample a number of items from a spectrum whose breadth and depth are defined only by the limits of the field itself. Kane and his colleagues have done well with the main course for the smorgasbord. The underlying theme of all the essays, and the integrating force of the book itself is epidemiologic. The papers range from those on classical epidemiology to its applications in health services research, evaluative studies both of the quality of care and of operating programs and to the applications of the basic science of public health in some of the newer applied areas such as environmental health, occupational health, population dynamics and the psychosocial factors in disease etiology. The author’s bias to this end ‘is one we happen to share. But where are the appetizers? Although the individual contributors sometimes make points about the history of community medicine, from their various vantage points, the rich history of the field is not summarized in any specific place so that the reader can quickly and concisely appreciate the growth and development of a growing field to its present state as both art and science. One tends to associate the beginning of modern community medicine in this country with the early work of Deuschele et al. in Kentucky. In truth, however, it is just as easy to associate this development with the early work of John Grant, the real father figure who gave the field its name. Grant’s work was primarily international. To ignore the international contributions to this discipline is to lose sight of one of its important developmental dimensions. In a similar vein there is no acknowledgement of the work of some of the current international contributors, e.g. the British practitioner-epidemiologist, Dr. John Fry, whose work on the epidemiology of medical practice, tends to excite those students who are privileged enough to be exposed to it. And what about dessert, that favorite course for which we all wait? Although the editor and a number of contributors grew up in the sixties, when the practice of community medicine in the United States was in its adolescence, there is no chapter specifically allocated to the development of a program. Because of this lack, the interest of the actionoriented student who wants to “lay on hands” may never be captured. Hopefully some are and will continue to be sufficiently motivated to browse through some of the excellent references that appear at the end of each chapter. Back to the book in search of an audience. There is a glossary of terms at the end of the book which is doubtless useful to the student studying for an exam. Most of these are explained in the individual essays and could readily be found in the index. This elementary glossary is followed by an appendix on how to teach epidemiology, a strange contrast of extremes. Where is the mean? This writer feels that it is probably among faculty members and graduate students in the applied health sciences although it can doubtless serve as a useful reference tool for the highly motivated medical or nursing student with a special interest in community health. Johns Hopkins University Baltimore, MD, U.S.A.
ELIZABETH J. KRAMER
Risks of Imprisonment, by DAVID A. JONES. Lexington Books, Lexington, Ma., 1976. 229 pp. $17.00. The Health
A cooperative effort between a lawyer-criminologist-professor and a state correctional system has resulted in a document which should have a very positive impact on the delivery of health service to prisoners. Dr. Jones has reported on an extensive research project in which he examined the effect of imprisonment on the
523
practice, populations served, and recruitment. Issues relating to resources and manpower planning in a primary care group practice are examined. Guidelines for estimating physician and nurse staffing requirements are described, based on their accessibility and availability and on patient care needs. Specialty to primary physician ratios are suggested, based on the Kaiser-Permanente medical care experience. Primary care is considered to be comprehensive in scope, and, therefore, should provide for the delivery of the relatively small percentage of health services that are utilized on a non-ambulatory basis. Moreover, exposure to acute care inpatient situations is regarded as an important source of professional stimulation and continuing education, and offers the primary care physician the opportunity to be introduced to new diagnostic and treatment techniaues. Useful guidelines are offered in designing _ _ a minimal data base for evaluating performance, and assess Human Values and Ethics DAVIDC. THOMASMA management decisions. The demand for services, high and rising costs, fragmenUniversity of Tennessee Center tation and lack of coordination of services, inequity in for the Health Sciences Memphis, Tenn., U.S.A. access to services, and the growing concept that health care is a right, rather than a privilege, are major forces causing changing patterns of health care. Moreover, major technological advances, the pluralistic medical economy, consumerism, and the free market ideology of the AmeriCommunity Hospitals and Primary Care, by JOHN H. BRYANT,ALLENS. GINSBERG,SETH B. GOLDSMITH,MAR- can health care system, as well as growing local, state, and federal government involvement is shaping future diGARET C. OLENDSKIand NORA PIORE. Ballinger, Camrections in primary care delivery. Dr. Bryant’s prediction bridge, Mass., 1976. 399 pp. $14.00 is that when health care is totally accepted as a right, hospitals will be regarded by government as public utilities, This book is based on a report produced by the Center and will be controlled as such. National Health Insurance for Community Health Systems of Columbia University will provide not only the impetus for regionalization of whose purpose is to evaluate, analyze, and attempt to bring primary care centers, but be a strong factor in their conabout a better understanding in the organization and delitinuing growth. He doubts, however, that the health care very of health care. system will be federally operated. The major premise of the editors is that the community This book is a useful, practical reference for hospital hospital is the logical place for coordinating the wide spectrustees, administrators, and medical staffs interested in trum of health services included in primary, secondary, and ambulatory and primary care, and a worthy text for schotertiary medical care. The community hospital is increaslars, students, and policy makers in the general. area of ingly being called upon to provide primary care services, community health serviqes. as well as the necessary leadership and direction in developing innovative ideas and implementing effective proLancaster General Hospital NIKITASJ. ZERVANOS grams. With medical accessibility to primary care due to Family and Community various demographic, social and economic shifts among Medicine Program urban and rural groups, as well as changes in reimburseLancaster, Penn., U.S.A. ment formulae, including Medicare and Medicaid payments and other third party payers, a marked increase in ambulatory visits to hospitals has occurred. The authors trace the historical attempts of the govern‘IIe IntekctuaUy Handicapped and their Families: A New ment and private interests in developing programs to solve Zealand Survey by A. A. MORRISON,D. M. G. BEA~LEY problems in primary care delivery, both in urban and rural and K. I. WILLIAMSON. The Research Foundation of the settings, including hospital-based outpatient clinics and New Zealand Society for the Intellectually Handicapped, hospital-sponsored primary care satellites. Statistical inforWellington, New Zealand, 1976. 211 pp. $7.50 mation of emergency room use for urgent and non-urgent patients, bed size, population served, bed occupancy and teaching status is provided and expanded in an extensive This book presents the findings of an ambitious survey appendix to determine how these factors influence a hospiwhich the New Zealand Society for the Intellectually tal in developing primary care programs. Handicapped carried out in order to determine the prevaFive case studies of various hospitals were reported. lence of mental handicap in their country, to investigate Although the Hunterdon experience in Flemington, New the characteristics and needs of the individuals identified Jersey, was included among these case studies; the conand to explore the impact which the handicapped have siderable role of hospitals in the new specialty of family on their families. The research was designed to provide practice was not stressed adequately. There are now over the information, on which a rational and systematic 300 residency programs and, through their family practice approach to the planning of services could be based. centers, are paving the way for innovations in hospitalThe regions of New Zealand which were surveved insponsored primary care development. With more medical clude a quarter of the country’s population and were graduates seeking family practice residencies than positions selected for their representativeness. All available official available, the authors still remain entrenched in, the belief and voluntary sources were. used to identify those people, that the long-run tendency is for medical graduates to preaged O-64 who were “unable to lead independent lives in pare for traditional specialty practice. the community because of reduced intellectual functioning In a book of this type with 19 different authors and and impaired social adaptation” (p. 11). The parents, or 13 chapters covering overlapping issues, some redundancy parent substitutes, of nearly 90% of the sample were interis inevitable, especially on such subjects as organizational viewed concerning the handicapped individuals’ abilities, behaviour and requirements for daily care. They were and fiscal planning, health manpower, grouping of medical
cations, but of rational control over directions. We have little freedom left about applying medical technology, or medical systems. Our freedom must be exercised in gaining control of the directions of our technology. Consequently, biomedical ethical questions and theories must shift from personal and social to technological. What directions should our technology and medical systems take toward bringing about the proper ends of a good human life? Hence, I must agree with the map presented by Jongen and Helligers, a map of still uncharted ethical principles devoted to the common good. This book is a first step in that direction. It should be required reading for all students of health care, and for all interested in biomedical ethics. An excellent index enhances the strncture of the book, while the small print hinders comfortable reading of the more difficult passages.
524
Book reviews
asked to give details of the composition and financial circumstances of the family, and to describe what effect the handicapped person had on the relationships of the other family members. Finally they were questioned about the outside help, facilities or services which they used, those which they would like to use if they were more readily available, and those which they expected to need in the future. This report provides comprehensive and dispassionate information on all these topics, in a manner which is entirely suitable for the purpose for which it is designed. However the first part of the book, in particular, makes somewhat dry reading for anyone with limited knowledge of New Zealand. There is little attempt to interpret or discuss findings, which is frustrating for any reader who can think of a number of alternative explanations. For example, changes in the distribution of prevalence and severity with age in adults are interpreted as resulting from differential death rates. The possibility that any individual may become progressively more able to integrate himself into the community is not considered. The large number of tables describing differences between the Maori and European populatrons are also of limited significance to the reader with little knowledge of the extent of social, economic or even geographic integration of the races. More generally there is a need for greater discussion of the ways in which the definition of mental handicap which is used, together with the method of identifying the sample, might influence the findings. The possibility of differences in identification rates is at least worthy of consideration when interpreting the similarity between the distributions of severity of handicap in upper and lower social and economic status groups. The greater incidence of mild subnormality among the lower status groups in a variety of countries is of course well documented. The book does, however, provide an extremely valuable store of information and its faults are mainly ones of’omission. The criticisms given here are those which an academic audience might make, but that is not the audience for which the book is primarily intended. MRC Medical Sociology Cinit Institute of Medical Sociology Westburn Road Aberdeen, Scotland
FIONA WILSON
Medicine, edited by ROBERT Springer, New York, 1974. 369 pp. $13.50
The Challenges of Community L. KANE.
The Challenges of Community Medicine impresses the reviewer as being a book in search of an audience. Although billed by its publisher as “providing for the student a comprehensive, straightforward text”, student is not further defined. The book is an interesting compendium of essays, which, with two exceptions, are all original contributions. In the first chapter, “Community Medicine: What’s In A Name?“, written by Kane himself, the author states his preferred definition as being that of Tapp and Deuschele: “Community medicine is the academic discipline that deals with the identification and solution of the health problems of communities or human population groups.” T’he rationale stated for this nreference is that it “allows for flexibility and scope in b&h teaching and research”. That chapter and several others are addressed primarily to medical students, thereby allowing one to assume that they are the audience to whom the book is addressed. If so, this is far from a perfect introductory text, at least in this reviewer’s eyes. We like to think of an introductory survey course in a synthetic discipline, such as community health, as being somewhat of a smorgasbord which allows
the learner to sample a number of items from a spectrum whose breadth and depth are defined only by the limits of the field itself. Kane and his colleagues have done well with the main course for the smorgasbord. The underlying theme of all the essays, and the integrating force of the book itself is epidemiologic. The papers range from those on classical epidemiology to its applications in health services research, evaluative studies both of the quality of care and of operating programs and to the applications of the basic science of public health in some of the newer applied areas such as environmental health, occupational health, population dynamics and the psychosocial factors in disease etiology. The author’s bias to this end ‘is one we happen to share. But where are the appetizers? Although the individual contributors sometimes make points about the history of community medicine, from their various vantage points, the rich history of the field is not summarized in any specific place so that the reader can quickly and concisely appreciate the growth and development of a growing field to its present state as both art and science. One tends to associate the beginning of modern community medicine in this country with the early work of Deuschele et al. in Kentucky. In truth, however, it is just as easy to associate this development with the early work of John Grant, the real father figure who gave the field its name. Grant’s work was primarily international. To ignore the international contributions to this discipline is to lose sight of one of its important developmental dimensions. In a similar vein there is no acknowledgement of the work of some of the current international contributors, e.g. the British practitioner-epidemiologist, Dr. John Fry, whose work on the epidemiology of medical practice, tends to excite those students who are privileged enough to be exposed to it. And what about dessert, that favorite course for which we all wait? Although the editor and a number of contributors grew up in the sixties, when the practice of community medicine in the United States was in its adolescence, there is no chapter specifically allocated to the development of a program. Because of this lack, the interest of the actionoriented student who wants to “lay on hands” may never be captured. Hopefully some are and will continue to be sufficiently motivated to browse through some of the excellent references that appear at the end of each chapter. Back to the book in search of an audience. There is a glossary of terms at the end of the book which is doubtless useful to the student studying for an exam. Most of these are explained in the individual essays and could readily be found in the index. This elementary glossary is followed by an appendix on how to teach epidemiology, a strange contrast of extremes. Where is the mean? This writer feels that it is probably among faculty members and graduate students in the applied health sciences although it can doubtless serve as a useful reference tool for the highly motivated medical or nursing student with a special interest in community health. Johns Hopkins University Baltimore, MD, U.S.A.
ELIZABETH J. KRAMER
Risks of Imprisonment, by DAVID A. JONES. Lexington Books, Lexington, Ma., 1976. 229 pp. $17.00. The Health
A cooperative effort between a lawyer-criminologist-professor and a state correctional system has resulted in a document which should have a very positive impact on the delivery of health service to prisoners. Dr. Jones has reported on an extensive research project in which he examined the effect of imprisonment on the