Book Review
The handbook of social studies in health and medicine
Gary Albrecht, Ray Fitzpatrick and Susan Scrimshaw (eds)
ISBN: 0-7619427-2-6,; 2000; 545, pages; London: Sage;
Fran Collyer
Department of Sociology and Social Policy, University of Sydney, Sydney NSW
There are a number of texts on the market which offer sociological pieces on health and illness, but very few provide material as varied and analytical as does The Handbook of Social Studies in Health and Medicine. Here we are treated to a smorgasbord of delights with some excellent forays into the historical, political, and economic aspects of health and health care services. The book is intentionally inter-disciplinary, from fields as diverse as sociology, epidemiology, anthropology, politics, health services management, and health policy.
The Handbook is organised into three sections, 'Social and cultural frameworks of analysis', 'The Experience of health and illness', and 'Health care systems and practices'. The logic behind this organisation is not quite clear, as some of the chapters would be better placed elsewhere. For example, McHorney's chapter on measurement, and Trotter's chapter on network analysis have very little in common with other chapters in 'The Experience of Health and Illness', and both should have been placed in the first section alongside other chapters on method.
In each section we are provided with about ten chapters, (32 in all), mostly by authors working in Canada, North America, and England. Two are from Australia, and there are one each from Scotland, Germany, and Israel. These country designations are telling: only two chapters (Margaret Lock, and Linda Whiteford and Lois Lacivita Nixon) depart from the British-North American perspectives to offer a glance toward other parts of the world, namely South America, Africa, Asia or the Pacific. Even Turner's chapter, (which is otherwise an intriguing historical insight into the social construction of health and disease), keeps to the standard fare of Galen's four humours, the Judeo-Christian legacy, Descartes and the rise of scientific, rational medicine. This means the book does not provide a comprehensive understanding of how health and medicine have been constructed historically, nor offer a sufficiently wide range of cultural and social perspectives on health and medicine. For example it fails to even mention an Islamic perspective or Islamic form of health care system-despite the recent upheavals and strident public debates about exclusion and domination in the global system.
There are nevertheless many strengths within the book. One of the chapters I find most useful is written by Stephanie Robert and James House. This examines the major frameworks that have been used to analyse and measure socioeconomic inequalities in the British, American, Canadian and European contexts. Although it is a complex area, these authors manage to clarify issues and methods that are often poorly mistreated in texts. They organise, categorise and provide an overview of a wealth of literature, and yet keep the reader attentive throughout. Quite an achievement!
Another of my favourite chapters is by Donald Light. Although it too suffers from British-North American myopia, we are offered a resounding critique of economic theories of the market (and particularly the 'free' market), of neo-liberalism, managed competition and privatisation. Light examines the shifts in health policy toward market focussed strategies which have occurred in North America, Australia and Europe, and offers an insightful and thorough review of the evidence.
There are so many other chapters that it is difficult to decide which are worth a mention. Perhaps one of these should be the chapter by Sarah Cunningham-Burley and Mary Boulton titled 'The Social context of the new genetics'. This piece is quite fascinating, discussing the rise of genetic science and the social and political story of the project to map the human genome. Another might be the chapter by Deena White, 'Consumer and community participation: a reassessment of process, impact, and value'. This tells us a little about the history behind the participation of various 'stakeholders' in the health policy process, pointing out which of these grew from social movements, and which from explicit strategies of those already ensconced as 'insiders'. White shows us that the process of participation has not been linear, but marked by both progress toward greater representation and retreat back toward the central control of medical and administrative groups. The chapter offers an analysis of the diverse factors that have driven lay and community participation in America and Canada, and a review of the evidence of the impact of their inclusion. The central question for the author is why 'governments and other authorities determined to continue investing in lay participation with so little evidence of its impact'. White's answer is that this effort is made not for the benefit it might bring to the health care system or to patients, but to the authorities themselves. That in fact, lay participation enhances the power of decision-makers, as the dialogue and debate engendered by the process of community consultation provides government with an appearance of accountability and democratic process. In the case of Oregon, by appearing to share the process of decision-making, 'participation' encouraged citizens to accept the legitimacy of the rationing of health care services.
The least interesting chapter in the book is 'Resources and rationing: managing supply and demand in health care' by Stephen Harrison and Michael Moran. I give it this status because, as a sociologist, I expect a degree of theory and reflexivity. But the chapter is also turgid in its delivery and limited in its critical analysis: reducing, for example, the increasing use of technological solutions in medicine to consumer or physician demand.
Despite the limitations identified above, The Handbook offers something of interest for most of us researching or working in the health care sector. The chapter by Mary-Jo Delvecchio Good and Byron Good on the clinical doctor-patient relationship would be of value to those involved in the education of medical workers. Given the centrality of taking patient histories, the analysis of how students are taught to focus on only specific elements of a patient's experience, and thereby construct a medical narrative, should make a powerful addition to the medical curriculum. There is perhaps less on offer for those with an interest in politics, though perhaps Deena White's chapter might fill this need. Epidemiologists and those interested in measurement have several chapters to select from, including Sandra Lane and Donald Cibula's contribution on 'Gender and health', and Robert Trotter's on 'Ethnography and network analysis'. Sociologists, with their inherently heterogeneous spread of interests, are likely to appreciate at least half the book, but will certainly appreciate David Coburn and Evan Willis' chapter on the medical profession, Bryan Turner's 'The History of the Changing Concepts of Health and Illness: Outline of a General Model of Illness Categories', and Renée Fox's Medical Uncertainty Revisited.
The collection is rather too advanced as a text for first or second year nursing, health science, or sociology of health students (thought eminently suitable as a reference for their assignments). I use it however, with great success for masters level students, and find it a good personal resource for lectures in both health and welfare sociology courses.
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