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Book Reviews Population Health Division, Department of Health and Ageing, Canberra Tony McMichael has recently returned to Australia as director of the National Centre for Epidemiology and Population Health at ANU. He is highly regarded as an international scholar in epidemiology and environmental issues. His earlier books, par ticularly Planetary Overload (1993), have been highly acclaimed. This new volume, Human Frontiers, will further enhance his reputation. Professor McMichael tells a wonderful stor y of humankind. To explain the human condition and our challenges for the future, he interweaves threads from evolution, history, human biology and genetics, epidemiology, environmental and molecular sciences, sociology and politics. He evokes the Four Horsemen of the Apocalypse (Famine, Pestilence, War and Conquest) as the bearers of human disease and disaster. These horsemen, now thundering into the new millenium, continue to be driven by environmental change, biological evolution, and by the complexities of human nature. Can the human story have a happ y ending? Can human beings understand themselves well enough to take better care of each other, and of planet Earth? Can we understand enough about the microbial and physical environment to protect ourselves from disease, starvation and extinction? Can we control obesity, mental illness and the other epidemics of affluent life? Can we control the genie of genetic manipulation? You should read the book, consider the evidence, ponder the questions asked by the author and decide for yourself. For me, the book succeeds at many levels through its breadth of scope and depth of scholarship. The content is relevant, informative and often fascinating and sur prising. Professor McMichael writes with humour and scientific humility. He understands and synthesises knowledge across many disciplines. Although he offers conclusions, he is rarely dogmatic. He prefers to let the evidence stand for itself and to identify new questions arising from gaps in knowledge. On rare occasions only does Professor McMichael write as an advocate as well as a scientist. The emphasis on biological mechanisms and evolutionary adaptation is a major strength. For example, hominid genes adapted to the environment and lifestyle of the Pleistocene are not necessarily optimal for humans today. Even genes that worked well for hunter-gatherers can contribute to diabetes and obesity following the change to agricultural food-products and sedentary lifestyle. The biology of ageing is explained using the model due to Penrose, popularised by Medawar and Williams. Because environmental causes of mortality act throughout life, more genes 2002 VOL. 26 NO . 2 have been passed to the next generation from younger than from older parents. As a consequence, mutations with deleterious effects in early life are more effectively removed b y natural selection than are those that cause har m only in later life. The accumulation of mutations with deleterious effects of delayed onset contrib utes to the somatic deterioration that we identify as biological ageing. Surprisingly, Professor McMichael suggests (p. 203) that such genes should act from the age of 30 years or so, and that therefore there is little evidence that such genes actually exist. However, there is ample evidence, well known to life insurance companies, for strong genetic influences on longevity. Furthermore, genomic research has now identified specif ic genes affecting the general rate of ageing, as well as cardiovascular disease, diabetes, cancer, Alzheimer’s disease and other diseases of later life. Biological mechanisms are linked to social and environmental determinants at many levels. For example, hunter-gatherers were taller in stature than their agricultural descendants. There was also stunting of g rowth of socially disadvantaged town dwellers until well into the 20th century (p. 138). McMichael quotes from the 1884 Dictionary of Statistics: ‘Fellows of the Royal Society are 3.9 inches taller and 21 lb heavier than burglars and other convicts’. Communicable diseases such as plague caused recurrent epidemics in Europe. Smallpox, tuberculosis and other diseases introduced from Europe had devastating impacts on indigenous populations in the Americas and Oceania; sexually transmitted diseases added to infertility and depopulation. Until recently, the heavy burden of communicable diseases in squalid and overcrowded towns and cities was largely responsible for high rates of infant mortality and reduced life expectancy. Conditions in industrialised countries began to improve with the public health refor ms introduced from around 1850. Similar reforms have yet to be completed in many developing countries. McMichael cites evidence, from McKeown and others, that poor nutrition was responsible for historical stunting of growth, for impaired immunity, and thus for high death rates from communicable diseases. For example, in the 1960s, malnourished children in Central America were much more likely to die from measles than US children. However, malnutrition may not be the whole stor y. Overcrowding facilitates cross-infection, with a higher average infective dose and greater vir ulence. This can help explain the impact of communicable diseases in the overcrowded towns and cities fed by crops from ag riculture. The poorer health of such populations is associated not only with nutritional change, but also with higher population densities leading to higher rates of cross-infection. The causal pathways are undoubtedly complex. Infections can also impede nutrition, stunt growth, and contribute to immune suppression, so that a vicious circle can arise, with positive feedback between poor nutrition and communicable disease. In previous generations, unhealthy and poorly nourished mothers bore smaller babies, with high mortality predominantly from communicable diseases. McMichael cites the detailed analysis of AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Book Reviews mor tality trends from 1840 (by Kuh and Davey-Smith, 1993) to show that persons born in England around 1850 had g reatly improved survival at all ages, except in infancy. Inf ant mortality rates only began to fall from 1875, suggesting that there had to be a generation of healthier mothers to bear infants with a greater chance of survi ving. In recent generations, birth weights have risen in developed countries, and all infants are much more likely to survive. However, infants of low birth weight still appear to be at higher risk of diabetes mellitus and cardiovascular disease in adult life. Such effects are most evident in socially disadvantaged groups. For example, low birth weights in Aboriginal Australians predicts renal disease as well as diabetes. Obesity the most important risk factor for (type 2) diabetes, is , assuming epidemic proportions in developed and developing countries alike. We attribute it to the modern diet and to greatly decreased physical activity. Yet we have few solutions. Professor McMichael deals with most of the other difficult challenges of modern society – including substance abuse, antibiotic-resistant bacteria, environmental degradation. He defines the problems with admirable clarity but does not insult the reader with over-simplistic solutions. The book is well organised and well produced. Excellent endnotes, references and index enhance its value. The tables and figures are appropriate and instructive, many original to this work. The book deserves to be read by all those with an interest in the human condition. It should also be recommended as a text for students in the health and environmental sciences, public health, social sciences and humanities. Inevitably, in such an ambitious work, there are some minor lapses. On page 23, it is implied that increasing rates of poliomyelitis and asthma in the 20th century were caused by similar mechanisms. This confusion is clarif ied on page 121. There is an inconsistency between the text (p. 55) and Fig. 2.3 with the timedepth for human colonisation of Australia. Folic acid is confused with pyridoxine on page 62. Occasionally, the writing assumes knowledge known only to the cogniscenti. For example, the reference to pinta on page 98 would be lost on most readers, including many medicos. Technical ter ms are sometimes used inappropriately: for example, on page 103, Professor McMichael applies the term ‘immunogenetic lability’ to microbes, rather than to genes determining the immune response against microbes. Tony McMichael’ book represents a major intellectual contris bution to public health. Many of his admiring friends and colleagues, myself included, would wish for the ability to have written it themselves. Public and Private Roles in Health Care Systems – Reform Experience of Seven OECD Countries By Claudia Scott. Open University Press: UK, 2001. 184 pages, paperback. RRP $55. ISBN 0 335 20459 7 Reviewed by Abby Bloom Health Innovations International Pty Ltd Public and Private Roles in Health Care Systems, which is part of a ‘State of Health’series, is an excellent primer for those seeking to broaden their understanding of health reform from an economic perspective. The health refor m history of seven OECD countries is summarised in a succinct volume using a comparative policy perspective. The three core chapters present the country experience of each, with countries grouped according to the similarities among their health system models. Thus Germany and the Netherlands (both ‘Bismarckian’ social insurance systems) are considered together; the US, Canada and Australia (complex systems straddling various levels of government and with a dispersion of funding, purchasing and provision responsibility) are grouped; and the UK and New Zealand. The f irst two chapters provide an over view of the theoretical approach and analytical perspective used and a useful review of alternative roles and key economic concepts in the analysis of health systems. The strengths of the book – its economic perspective on health reform and its brevity – are also its main weaknesses. The book contains a tight factual description and analysis of each of the seven systems. It adheres strictly to the economic framework it proposes for understanding the reform experience and system performance, so that the aspects of system performance it addresses are limited to four that are, understandably, of highest priority to economists: efficiency, cost containment, equity and choice. Thus, although the f inal chapter asserts that the book has demonstrated how certain configurations of public and private roles ‘. . . are more effective than others in promoting better health outcomes . . .’ (p.145), this is not the case. ‘Health outcomes’ (i.e. the impact of alternative health care systems of health status) and other critical performance indicators of health systems are in fact not within the scope of the volume. Also excluded are such factors as consumer satisfaction; equity def ined as actual utilisation, not merely equity defined as in principle; and equity and access in terms of total affordability to the end user, including access delayed through rationing and insuperable opportunity costs. Another concern for the student of comparative health systems, and even more for experts in the f ield, is an apparent reluctance to come to any conclusions about the individual or comparative merits of the seven systems. For example, many observations about the individual health systems are couched in language such as ‘It has been suggested that . . .’ or ‘. . . one estimate suggests that AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 26 NO. 2 Book Reviews . . .’. It is fair to expect that an authoritative text such as this would have avoided such arms-length language and concluded that the references used are either based on sound methodology and therefore reliable, or discarded them. The impression that the author is uncertain about the reliability of much of the reference material might have been avoided by more diligent editing. At the next level, each system is analysed in ter ms of efficiency, but the concluding chapter contains no attempt to compare and contrast them on the parameter of efficiency, or any of the other three dimensions of the framework. It would have been useful to have a concluding section on each of the four key dimensions of the framework. Finally, the author’ infor med opinions would have s been useful, even with the caveat that different mechanisms and systems suit different political, cultural and economic settings. In conclusion, Public and Private Roles in Health Care Systems is a helpful reference manual for an yone seeking a short, sharp description of health reform in seven OECD countries during the 1980s and 1990s. It will be particularly useful in health economics courses and in courses that compare contemporary health care systems. native to the vexed limits to claims of any evidence-based knowledge that do not realise the y are contingent, contextualised, constr uctivist and temporal. Richard Winter and Carol Munn-Giddings have been leading theorist-practitioners in the UK over a period spanning three decades. They have produced a book that translates well to the Australian context, where it should fur ther illuminate action research in health and human services, as did Robin McTaggar t and Stephen Kemmis’ Action Research Planner in education and the texts of Ortrun Zuber-Sker rit in business/management. There are 11 interestingly written accounts of small-scale health and social care action research projects, ranging from developing innovative nursing practice (e.g. bedside handovers) or in child protection (e.g. assisting child witnesses), through to urban regeneration, examining the positive experiences of black social workers, and consumer research (in mental health and cancer self help). They are contributed by experienced and sometimes key players in their f ields, and illuminate in var ying ways different action research lear ning and guiding principles to date. These include: the business of involving ever yone who is relevant; the implications of working further afield as the systemic nature of issues expands who is ‘relevant’; the need for emotional/peer support to any involved in transforming practice; the signif icance of facilitation skills and e xperience and how best to position this task; the extent of resources and care needed to enable people to speak to each other across silencing disparities of power; the connections between the ‘personal’ and the work problem at hand; the relative simplicity and do-ability of small-scale inquiry; the problems of goal displacement if action research is the aim rather than being a means to address a substantive issue; and the breakthroughs possible when it is done well. In Part 3, Richard Winter publishes his own (action research course notes) teaching about how to go about undertaking an action research project. Part 4 provides a coherent and succinct theoretical justification that deconstructs its controversial nature as stemming from the politically equalising nature of a discourse that admits various stakeholders’ knowledge as important (in the face of other discourses constr uing them as not). This formulation goes beyond the potential dead-end of inter pretive relativism per se, or the potential idealism from an epistemology that sees any knowledge as possible or unconstrained by an at least (and non-positivist) implied or assumed (I prefer ‘agreed’) but always fallible ‘reality’ (drawing on the work of Bhaskar), and situates action research instead within ‘critical realism’, described with commendable clarity and elegance. This is a jewel of the international action research literature that may be ver y useful for existing action researchers as well as those teaching or enrolled in research courses. It would also be worthy of the attention of any general health and human services researchers (including practitioners and consumers) interested in thinking fur ther about their own practice. A Handbook for Action Research in Health and Social Care By Richard Winter and Carol Munn-Giddings. Routledge: UK, 2001. 281 pages, paperback. ISBN 0 415 22484 5 Reviewed by Yoland Wadsworth Institute for Social Research, Swinburne University of Technology How marvellously liberating to read a newly published book that is nigh identical to that which one is in the middle of writing! Liberating because the authors have done such a v ery satisfying job of it (and also because I now don’t have to cover this ter ritory). The f irst 62 pages of this book alone represent a readable and concise state-of-the-art scan across what is a very large ter ritor y (I imagine it may go straight into readers’ packs). This particular book sits within a recent burgeoning literature on action research that, in turn, reflects a growing coherence and conf idence among practitioners of an epistemology that has benefited from both constant contestation by the (moder n) mainstream scientific discourse and from the mutual support and discourse-constr uction from within its own fast-g rowing ‘community of science’. It is a paradigm that senses its time has come, given its peculiar suitedness to a complex postmodern world of multiple viewpoints, multiple realities and contested desires for a variously ‘better world’. With its offer of a non-violent, democratised and systemic approach to hearing from ‘the multitude of counsellors’ (that’s citizens, not parliamentary representatives!), it holds out an alter- 2002 VOL. 26 NO . 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Book Reviews Researching Health Promotion By J. Watson and S. Platt (eds). Routledge: UK 2001. 279 pages, paperback. ISBN 0 415 21591 9 Reviewed by Marilyn Wise Australian Centre for Health Promotion, New South Wales Researching health promotion is a hot topic in the field. There are many signif icant issues to address if there is to be improvement in the relationships between research, policy and practice. Some of these include the need for more systematic, purposive development of theor y, and the more systematic transfer of research f indings into health and public health policy. The evidence base has been growing, but it lags behind our understanding of social and economic determinants of health, and behind knowledge of the components of effective or quality inter ventions. The tools developed to assist in guiding evidence-based practice have led to ‘conflation of the effectiveness of an intervention with the effectiveness or ‘quality’ of its evaluation’.1 This book promises to ‘make a significant contribution to ongoing epistemological, theoretical and methodological debates in health promotion research’, advocates the better use of theory to guide research and practice, and stresses the need for greater theory development. It promises to give practitioners, researchers and policy makers new insights into the challenges for health promotion research and to provide examples of ‘good practice’. The concept of the book is excellent. Divided into three sections, it opens with discussion of key philosophical, theoretical, conceptual and practical challenges for contemporary health promotion and research – connecting research with policy and practice, repositioning health promotion as a focus of policy upstream, integrating environmental sustainability into the health promotion agenda, and the use of a more sophisticated theoretical approach to promoting health-related lifestyles. Section two raises methodological challenges, beginning with an in-depth discussion of postmoder nism and health promotion. This is followed by two examples of the use of different research methods to guide and suppor t intervention design, implementation and evaluation and an exploration of the contribution of economic theory and research to health promotion. Section three includes examples of good practice – that is, of research integrated with practice on a range of issues and in different settings and population g roups. However, despite some ver y good chapters, the book does not deliver on its promise. There is no analysis that links the strategic and theoretical challenges and methodological issues raised in the first two sections with the examples of good practice. It reads, therefore, more as a series of interesting, b ut unconnected papers that would be more accessible to the audiences through peerreviewed literature. There is no discussion of the ways in which these examples illustrate, specifically, ideas raised in the earlier sections. This is disappointing, because the individual examples do appear to be well-designed and implemented projects that integrate research with intervention (for the most part). There is a relatively high level of detail provided about the relationship between research and program development and design and about the interventions themselves. The examples have been written for readers interested in the quality of interventions as well as in the quality of research. In this sense, it is refreshing to find a focus on intervention research, as well as evaluation. That makes it all the more disappointing that none of the projects presented in these chapters addresses social or economic determinants of health, few used social or organisational theory to assist in program design or implementation, all but one described levels of risk only in individuals and, as a consequence, those that presented evaluations used only outcome measures of individual behaviour change. In all, there is no analysis of the programs or of the research in relation to the fresh thinking and methodological challenges that were posed in the opening sections of the book. The section on good practice serves, in fact, to bring into even clearer focus the gap that exists between the cur rent research base and what is needed in terms of theory, methods, polic y and practice if it is going to be possible to address the significant challenges to population health that have been identif ied already. For teachers wanting case studies of well-designed research linked to program design and deliver y (albeit individual behaviour-change programs), the book offers some good examples. For researchers looking to expand the range of theory and research methods that might be used in health promotion research design, there are some useful ideas. For practitioners seeking benchmarks of good practice, it does provide some e xamples. For policy makers, the chapters on strategic and methodological challenges pose some useful questions. But for those looking for inspiration and guidance on the application of an expanded range of research methods (and theory) to guide and support action to address the major challenges to the health of populations now and in the future, the book is not recommended. Reference 1. Watson J, Platt S. Connecting policy and practice: the challenge for health promotion research. In: Watson J, Platt S, editors. Researching Health Promotion. London: Routledge, 2000. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 26 NO. 2 Book Reviews Community Informatics: Shaping Computer-Mediated Social Relations By L. Keeble and B.L. Loader (eds). Routledge: UK, 2001. 388 pages, paperback. ISBN 0 415 23112 4 Reviewed by Chris Peterson School of Public Health, La Trobe University Victoria , This book contains 19 chapters, contrib uted from a conference in 2000 organised by the Community Informatics Research and Applications Unit, University of Teesside, UK. It is a collection of papers by practitioners, academics and other experts that debate the ways in which information technology can effect, develop and transform various aspects of community relations. The edited papers focus on community informatics, which the editors point out is a field of study for investigating cultural and social factors that shape information and communication technology and the effects of this technology on community development. It is a mixture of practical applications of the technologies and of concepts relevant to understanding just how the technologies affect several community aspects, including sense of spatial relations, time and distance, and community organisation. This book is organised into four sections: community infor matics as place and space; the experience of community infor matics; electronic empower ment and surveillance; and polic y implications of community informatics. There are some excellent chapters that introduce important advanced technology and community concepts. These traverse a range from theoretical discourse to ver y practical appraisals of projects and experiments in the role technology has for developing community relations. One of the introductory chapters, on physical place and cyberspace, looks at the role of the Inter net and other advanced technologies in shaping spatial relations in the community. The authors conclude, among other outcomes, that at present the mobile phone offers a g reater creative oppor tunity to exploring spatial relations in the community than the Internet. However, the author creatively evaluates the Internet for its impact on community formation and organisation. Another chapter considers the important topic of the development of self help and support g roups through the use of IT, and provides some useful case material to show how practices such as computerassisted social suppor t can be a ver y effective. It was pleasing to see chapters adopting a critical perspective on women, the community and IT, and a par ticularly benef icial, critical commentary made on male surveillance of female privacy in the use of close-circuit TV systems. One useful and welldeveloped chapter identifies and critically reviews a number of theoretical perspectives in developing a perspective on the contribution of advanced technology to community development and empower ment. In addition, there are a number of discussions in different chapters on social capital as enhanced by the Internet and other advanced technologies. This book is an exciting read, but not altogether easy. I felt there was a need for further discussion in the f irst chapter, by the editors, to point out some key issues in the use of advanced technologies and interfaces between the technology and communities of people. This may have taken the form of identifying some issues such as the effects of technophobia and age on community acceptance of IT, and an evaluation of power relations between technologists – who often drive Internet and advanced technology development – and the extent to which new technologies need to be meshed with satisfying human needs across a range of perspectives, including social, emotional and psychological. This collection contains a small glossary. Although this is useful, it could have contained the large list of abbreviations that occur red in the text, plus full descriptions. This is not a book for everyone; it is more for those who specialise in infor mation technology and/or community relations, and for this readership the book will enhance the debate on community infor matics. For a wider readership, the book could have been more focused on defining concepts and led the reader through a theoretically driven discourse, building concepts along the way. The book covers a lot of g round and requires some reasonable understanding of advanced technology to gain maximum benefits. However, it offers some exciting discussions of front-line developments in the area from across the world and should stimulate some creative solutions to community development. 2002 VOL. 26 NO . 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Book Reviews Home truths about domestic violence: feminist influences on policy and practice, a reader By Jalna Hanmer and Catherine Itzin (eds) with Sheila Quaid and Debra Wigglesworth. Routledge: UK, 2001. 408 pages, paperback. ISBN 0 415 24157 X Reviewed by Angela Taft Centre for the Study of Mothers’ & Children’s Health, La Trobe University Victoria , Ann Flitcraft argued, in an article in a 1992 issue of the Journal of the American Medical Association , that the epidemiology of rape, physical and sexual assaults in marital, cohabiting and dating relationships and long-term effects of childhood sexual abuse reveals women’s vulnerability to abuse across the lifespan.1 The continuing problem, concludes Catherine Itzen in this new, largely British reader, is degendered language and the absence of ‘the violent male’ in domestic violence policy. This is an insurmountable obstacle, she argues, to domestic violence prevention. All other policies (aid to women through refuges, and housing, multi-agency for ums, police domestic violence units and legal sanctions) can be regarded as damage limitation and harm minimisation policies. Itzen’s critical and pessimistic over view of domestic violence policy directions in the f inal chapter of this book is cautionary and relevant to an Australian context. This new comprehensive polic y reader is aimed at both academics and multi-disciplinary professionals, teachers and students (including those in health and welfare) w ho may either manage or provide care for victims, perpetrators and their children. The book aims to provide a combination of feminist theory of violence against women together with a historical perspective on how research and activism has led to shifts in both the understanding of, and responses to, violence against women, men w ho use violence and, more recently, their children. This reflective re-evaluation of policy and practice seeks to provide a context for change both in the UK and more broadly in the global agenda. The book is loosely str uctured, variable in quality and draws together new and previously pub lished British research on domestic violence policy and practice. It illustrates the concept of Flitcraft’ continuum and the har m minimisation practices, which s Itzen critiques. The two of 20 chapters from American leaders in their field provide useful contrasts to the British contributions. For those with an interest in critical analysis of domestic violence policy and practice, this book provides a useful (and updated) comparison with McGregor and Hopkin’ excellent 1991 account s of Australian polic y development, Working for change: the movement against domestic violence.3 A more health-system-specif ic analysis of policy and practice can be found in Stark and Flitcraft’ s 1996 book Women at Risk. 2 Unlike the 1991 Australian account, Home Truths analyses the trends in responses to children and evaluations of American and British responses to men who use violence. These latter chapters conclude, as Itzen does, that men’s behaviour change programs are somewhat effective only for the men arrested and convicted. This is a very small proportion of those abusive to women and unlikely to change, says Itzen, without concerted intervention by the state. For sociologists or policy analysts, I would single out the contribution of Pragna Patel, a Kenyan Indian Hindu immig rant woman, who thoughtfully examines the intersections of violence, gender, race and class in chapter 10. This chapter moves in an intelligent analytic flow from her own identity crisis to the collective actions against male violence of the Southall Black Sisters and their campaign to free Kiranjit Aluhwahlia, jailed for the murder of her violent husband. From here, Patel probes the relations between the state and family as it applies to black and immigrant f amilies, and moves to a spirited critique of multi-culturalism and religious fundamentalism, gender and violence. Her analysis is illustrated by her involvement in progressive alliances both within Britain and between Britain and India, and together with Amina Mama’s study (Chapter 3) provides considerable insight into the struggles for justice and suppor t by black and immigrant women in racist and se xist cultures. For health and welfare policy-makers and practitioners, the book’ interest lies in those chapters providing detailed reflection s and evaluation of overseas strategies. This includes programs for children in refuges and child protection services, analyses of EMERGE, a founding men’s behaviour change program in the US, new UK evaluations of men’ programs by the Dobashes and s chapters on developing multi-agency responses. For those interested in Australian policy and practices towards victimised women, children and abusive men, and an e valuation of the ACT Interagency Family Violence Intervention Program, gover nment funded reports can be downloaded via the Office for the Status of W omen’s Par tnerships Against Domestic Violence website at http:/ /www.padv.dpmc.gov.au/ This book is recommended for public health academics, policymakers and practitioners interested in women’ policy iss sues. It serves as a reminder of the importance of engendering health policy and provides useful comparisons with Australian domestic violence policy and practice. References 1. Flitcraft A. Violence, v alues and gender. J Am Med Assoc 1992; 267:3194-5. 2. Stark E, Flitcraft A. Women at Risk: Domestic Violence and Women’s Health. Califor nia: Sage, 1996. p. 264. 3. McGregor H, Hopkins A. Working for Change: The Movement Against Domestic Violence. Sydney: Allen and Unwin, 1991. p. 150. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 26 NO. 2 Book Reviews Anxiety in a risk society By Iain Wilkinson. Routledge: UK, 2001. 165 pages, paperback. ISBN 0 415 22681 3 X Reviewed by Brendan Gibson Population Health Division, Commonwealth Depar tment of Health and Ageing Anxiety in a risk society aims to make anxiety a focus of sociological inquiry. This is a promising new angle for the sociology of risk, a literature that grew rapidly in the 1990s. By focusing on anxiety, the back cover says, ‘. . . a critical vantage point can be gained from which to attempt to answer the question: Are we more anxious because we are more risk conscious?’ This is an important question because of the burden of disease associated with mental illness and its projected increase. The book’s primary audience appears to be social scientists with an interest in mental health and the social determinants of health. The jour ney to the promised vantage point is in two parts. The first discusses anxiety in theoretical and empirical terms and reviews the psychological literature on ways of coping with anxiety. It chronicles the rise of the view that the modern age is an ‘age of anxiety’. While Wilkinson pays homage to sociology’s holy trinity of Marx, Durkheim and Weber, he gives Freud the primary role of ar ticulating the importance of anxiety in the modern world. He relies on Eric Fromm and Karen Horney, two mid20th century critical theorists, to make a connection between the individual experience of anxiety and rapid social change. In particular, Wilkinson connects the rise in anxiety with the demise of traditional values, beliefs and cultural institutions. The central thesis of the first section is that those who deal best with the anxieties of the modern world are those who have the cultural resources to give meaning to uncertainty and catastrophe. These resources are unequally distributed throughout society and lead to social inequalities in mental health problems. Although Wilkinson is keen to avoid the criticism that this thesis is built on ‘golden ageism’ – a belief that once upon a time and in some societies, humans lived happil y ever after – he does not put this criticism entirely to rest. The second par t of the book discusses the relationship between risk consciousness and anxiety. Wilkinson re views the histor y of the semantics of risk and theories of risk consciousness, particularly that of Ulrich Beck and Mary Douglas. He argues that Beck sees an increasingly hazardous world giving rise to an increasing level of risk consciousness and, perhaps, a reflexi ve capacity for positive social change. He argues that Douglas provides an opposing interpretation. Risk consciousness is the result of a desire for social solidarity in the f ace of perceived threats and is likely to lead to social conser vatism. Wilkinson’s promised ‘vantage point’ on this debate is that it is best seen as a politically motivated exercise that has resulted in little more than ‘castles in the air’. He argues that a focus on anxiety is the best way forward and that this should be linked to empirical work on the actual experience of the problems associated with anxiety. My assessment is that Wilkinson will f ind this ‘vantage point’ hard to hold and that he will not be rushed with disciples. One problem is that his treatment of the work of Beck, Douglas and others is too thin to sustain his savage critique. The major problem, however, is the strength of his alternative formulation. The lack of clarity around the concept of anxiety is most problematic. The closest we come to a def inition is as follows: ‘The term anxiety is a symbolic for m of culture representing a state of mind and emotion by which we are made to be convinced that we are in a situation of threatening uncertainty.’ (p. 17) I do not understand this sentence. What is clear, however, is that Wilkinson sees anxiety as the product of social forces beyond the control of the individual. This does not sit well with other parts of the book that emphasise individual agency. Wilkinson appears to view anxiety as a multidimensional concept that has both an individual as well as a social component. At times he describes it in terms of its difference to fear, but at other times he suggests there is a comple x relationship between anxiety and knowledge of fearful situations. Sometimes anxiety is primarily to do with meaning or the loss of meaning. At other times it is related to the sense of being overwhelmed and powerless, but Wilkinson does not dif ferentiate it clearly from depression. He wants to hold on to the idea that anxiety has a ‘quality of indefiniteness’ but also expects assent to grand claims such as ‘It is now a matter of sociological common sense to identify ourselves as li ving through a period of acute insecurity and high anxiety.’ (p 42) Getting a handle on the subtleties of Wilkinson’ s view of anxiety is made more difficult by an inadequate index that has just one entry for the term anxiety. To be more successful, this book needed to be much clearer about the concept of anxiety and make better sense of the relationship between individual agency and social structure. 2002 VOL. 26 NO . 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Book Reviews Forgetting compliance: Aboriginal health and medical culture By Kim Humphrey and Tar un Weeramanthri with Joseph Fitz. Northern Territory University Press, 2001. 122 pages, paperback. RRP $30. ISBN 1 876248 59 9 Reviewed by George Sansbury Faculty of Law and Management, La Trobe University Reviewed by Rhonda Galbally www .ourcomm unity.com.au This book addresses factors affecting patient compliance/noncompliance with ser vices and systems in the area of Aboriginal health. Its stated intent is to question effor ts to improve compliance in the Aboriginal context from the point of view of the nonAboriginal health provider’s systems and org anisational frameworks. In pursuit of this, the authors critically analyse the concept of ‘compliance’ and conclude that it is an inappropriate concept for several reasons. First, it represents a predominantly Western view of health and, second, it assumes that Western health systems and professionals have a superior legitimacy to alternative systems and beliefs. The book provides a succinct overview of the genesis and historical use of the concept of compliance and critically discusses the situation in Third World and indigenous populations. Review of the research data leads the authors to conclude that health professionals need to develop the ability to think about compliance beyond the conventional medical model. They recommend that such an approach be under taken with the aim of ‘critiquing and transforming institutional arrangements, organisational forms and decision-making structures’ (page 104) and to ‘confront provision and uptake issues beyond the bio-medical and clinical frame in terms of actively and vocally connecting improved health status and treatment outcomes to issues of socio-economic well-being and social justice’. (page 104) The authors choose to emphasise the first of these, i.e. the need to critique and transform institutional and organisational ar rangements, believing, reasonably, that this is most realistically within the ability of health professionals to affect. To this end the material concentrates on the institutional structure and process of health deliver y and provides a critique of the inherent ethnocentrism of professional health service to indigenous communities (i.e. within a Western biomedical context). From this, its intended audience of health providers, administrators and policy makers will gain an incisive insight into the issues concerning the inappropriateness of Western models to indigenous and non-indigenous health care alike. This approach echoes that of previous writing on indigenous policy and ser vice provision in that it places the locus of control and meaning outside of Western culture and institutions (Coombes, 1978).1 Although tackling social inequity is understandably considered by the authors to be an unrealistic goal for health professionals to take on alone, it is still of critical importance that health care enjoins with movements to fight for equity, justice and human rights. The book is timely and useful in this demand for Indigenous, community management and control of service deliver y in Aboriginal health. Indeed, this is a core issue, not only for Indigenous health care but also for efficacious outcomes in Western health care. Such emphasis – on transferring the dominant perspective to recipient g roups and communities – is echoed in research in social epidemiology w hich emphasises the dominant , role in community health of the impact of socio-economic status, community control and social justice factors (Syme, Marmot and Heyman 2000). 2 Thus, it would seem that the prevailing institutional and cultural paradigms need to be questioned with regard to all community health provision and not just that of Indigenous health. Therefore, the emphasis upon these institutional and cultural issues by the authors is of particular impor tance since any change of institutional paradigm has, as a prerequisite, the need for changes in values and perspectives on the part of the health service professional. In addressing the issue of perspective, the book is timely since health research suggests that a reconciliation of health service provision (in a Western, or any other, cultural model) to these factors is now required. Forgetting Compliance provides a focus for rethinking directions in health provision. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Book Reviews

Australian and New Zealand Journal of Public Health , Volume 26 (2) – Jan 1, 2002
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Wiley
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Copyright © 2002 Wiley Subscription Services
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1326-0200
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1753-6405
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10.1111/j.1467-842X.2002.tb00918.x
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Abstract

Population Health Division, Department of Health and Ageing, Canberra Tony McMichael has recently returned to Australia as director of the National Centre for Epidemiology and Population Health at ANU. He is highly regarded as an international scholar in epidemiology and environmental issues. His earlier books, par ticularly Planetary Overload (1993), have been highly acclaimed. This new volume, Human Frontiers, will further enhance his reputation. Professor McMichael tells a wonderful stor y of humankind. To explain the human condition and our challenges for the future, he interweaves threads from evolution, history, human biology and genetics, epidemiology, environmental and molecular sciences, sociology and politics. He evokes the Four Horsemen of the Apocalypse (Famine, Pestilence, War and Conquest) as the bearers of human disease and disaster. These horsemen, now thundering into the new millenium, continue to be driven by environmental change, biological evolution, and by the complexities of human nature. Can the human story have a happ y ending? Can human beings understand themselves well enough to take better care of each other, and of planet Earth? Can we understand enough about the microbial and physical environment to protect ourselves from disease, starvation and extinction? Can we control obesity, mental illness and the other epidemics of affluent life? Can we control the genie of genetic manipulation? You should read the book, consider the evidence, ponder the questions asked by the author and decide for yourself. For me, the book succeeds at many levels through its breadth of scope and depth of scholarship. The content is relevant, informative and often fascinating and sur prising. Professor McMichael writes with humour and scientific humility. He understands and synthesises knowledge across many disciplines. Although he offers conclusions, he is rarely dogmatic. He prefers to let the evidence stand for itself and to identify new questions arising from gaps in knowledge. On rare occasions only does Professor McMichael write as an advocate as well as a scientist. The emphasis on biological mechanisms and evolutionary adaptation is a major strength. For example, hominid genes adapted to the environment and lifestyle of the Pleistocene are not necessarily optimal for humans today. Even genes that worked well for hunter-gatherers can contribute to diabetes and obesity following the change to agricultural food-products and sedentary lifestyle. The biology of ageing is explained using the model due to Penrose, popularised by Medawar and Williams. Because environmental causes of mortality act throughout life, more genes 2002 VOL. 26 NO . 2 have been passed to the next generation from younger than from older parents. As a consequence, mutations with deleterious effects in early life are more effectively removed b y natural selection than are those that cause har m only in later life. The accumulation of mutations with deleterious effects of delayed onset contrib utes to the somatic deterioration that we identify as biological ageing. Surprisingly, Professor McMichael suggests (p. 203) that such genes should act from the age of 30 years or so, and that therefore there is little evidence that such genes actually exist. However, there is ample evidence, well known to life insurance companies, for strong genetic influences on longevity. Furthermore, genomic research has now identified specif ic genes affecting the general rate of ageing, as well as cardiovascular disease, diabetes, cancer, Alzheimer’s disease and other diseases of later life. Biological mechanisms are linked to social and environmental determinants at many levels. For example, hunter-gatherers were taller in stature than their agricultural descendants. There was also stunting of g rowth of socially disadvantaged town dwellers until well into the 20th century (p. 138). McMichael quotes from the 1884 Dictionary of Statistics: ‘Fellows of the Royal Society are 3.9 inches taller and 21 lb heavier than burglars and other convicts’. Communicable diseases such as plague caused recurrent epidemics in Europe. Smallpox, tuberculosis and other diseases introduced from Europe had devastating impacts on indigenous populations in the Americas and Oceania; sexually transmitted diseases added to infertility and depopulation. Until recently, the heavy burden of communicable diseases in squalid and overcrowded towns and cities was largely responsible for high rates of infant mortality and reduced life expectancy. Conditions in industrialised countries began to improve with the public health refor ms introduced from around 1850. Similar reforms have yet to be completed in many developing countries. McMichael cites evidence, from McKeown and others, that poor nutrition was responsible for historical stunting of growth, for impaired immunity, and thus for high death rates from communicable diseases. For example, in the 1960s, malnourished children in Central America were much more likely to die from measles than US children. However, malnutrition may not be the whole stor y. Overcrowding facilitates cross-infection, with a higher average infective dose and greater vir ulence. This can help explain the impact of communicable diseases in the overcrowded towns and cities fed by crops from ag riculture. The poorer health of such populations is associated not only with nutritional change, but also with higher population densities leading to higher rates of cross-infection. The causal pathways are undoubtedly complex. Infections can also impede nutrition, stunt growth, and contribute to immune suppression, so that a vicious circle can arise, with positive feedback between poor nutrition and communicable disease. In previous generations, unhealthy and poorly nourished mothers bore smaller babies, with high mortality predominantly from communicable diseases. McMichael cites the detailed analysis of AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Book Reviews mor tality trends from 1840 (by Kuh and Davey-Smith, 1993) to show that persons born in England around 1850 had g reatly improved survival at all ages, except in infancy. Inf ant mortality rates only began to fall from 1875, suggesting that there had to be a generation of healthier mothers to bear infants with a greater chance of survi ving. In recent generations, birth weights have risen in developed countries, and all infants are much more likely to survive. However, infants of low birth weight still appear to be at higher risk of diabetes mellitus and cardiovascular disease in adult life. Such effects are most evident in socially disadvantaged groups. For example, low birth weights in Aboriginal Australians predicts renal disease as well as diabetes. Obesity the most important risk factor for (type 2) diabetes, is , assuming epidemic proportions in developed and developing countries alike. We attribute it to the modern diet and to greatly decreased physical activity. Yet we have few solutions. Professor McMichael deals with most of the other difficult challenges of modern society – including substance abuse, antibiotic-resistant bacteria, environmental degradation. He defines the problems with admirable clarity but does not insult the reader with over-simplistic solutions. The book is well organised and well produced. Excellent endnotes, references and index enhance its value. The tables and figures are appropriate and instructive, many original to this work. The book deserves to be read by all those with an interest in the human condition. It should also be recommended as a text for students in the health and environmental sciences, public health, social sciences and humanities. Inevitably, in such an ambitious work, there are some minor lapses. On page 23, it is implied that increasing rates of poliomyelitis and asthma in the 20th century were caused by similar mechanisms. This confusion is clarif ied on page 121. There is an inconsistency between the text (p. 55) and Fig. 2.3 with the timedepth for human colonisation of Australia. Folic acid is confused with pyridoxine on page 62. Occasionally, the writing assumes knowledge known only to the cogniscenti. For example, the reference to pinta on page 98 would be lost on most readers, including many medicos. Technical ter ms are sometimes used inappropriately: for example, on page 103, Professor McMichael applies the term ‘immunogenetic lability’ to microbes, rather than to genes determining the immune response against microbes. Tony McMichael’ book represents a major intellectual contris bution to public health. Many of his admiring friends and colleagues, myself included, would wish for the ability to have written it themselves. Public and Private Roles in Health Care Systems – Reform Experience of Seven OECD Countries By Claudia Scott. Open University Press: UK, 2001. 184 pages, paperback. RRP $55. ISBN 0 335 20459 7 Reviewed by Abby Bloom Health Innovations International Pty Ltd Public and Private Roles in Health Care Systems, which is part of a ‘State of Health’series, is an excellent primer for those seeking to broaden their understanding of health reform from an economic perspective. The health refor m history of seven OECD countries is summarised in a succinct volume using a comparative policy perspective. The three core chapters present the country experience of each, with countries grouped according to the similarities among their health system models. Thus Germany and the Netherlands (both ‘Bismarckian’ social insurance systems) are considered together; the US, Canada and Australia (complex systems straddling various levels of government and with a dispersion of funding, purchasing and provision responsibility) are grouped; and the UK and New Zealand. The f irst two chapters provide an over view of the theoretical approach and analytical perspective used and a useful review of alternative roles and key economic concepts in the analysis of health systems. The strengths of the book – its economic perspective on health reform and its brevity – are also its main weaknesses. The book contains a tight factual description and analysis of each of the seven systems. It adheres strictly to the economic framework it proposes for understanding the reform experience and system performance, so that the aspects of system performance it addresses are limited to four that are, understandably, of highest priority to economists: efficiency, cost containment, equity and choice. Thus, although the f inal chapter asserts that the book has demonstrated how certain configurations of public and private roles ‘. . . are more effective than others in promoting better health outcomes . . .’ (p.145), this is not the case. ‘Health outcomes’ (i.e. the impact of alternative health care systems of health status) and other critical performance indicators of health systems are in fact not within the scope of the volume. Also excluded are such factors as consumer satisfaction; equity def ined as actual utilisation, not merely equity defined as in principle; and equity and access in terms of total affordability to the end user, including access delayed through rationing and insuperable opportunity costs. Another concern for the student of comparative health systems, and even more for experts in the f ield, is an apparent reluctance to come to any conclusions about the individual or comparative merits of the seven systems. For example, many observations about the individual health systems are couched in language such as ‘It has been suggested that . . .’ or ‘. . . one estimate suggests that AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 26 NO. 2 Book Reviews . . .’. It is fair to expect that an authoritative text such as this would have avoided such arms-length language and concluded that the references used are either based on sound methodology and therefore reliable, or discarded them. The impression that the author is uncertain about the reliability of much of the reference material might have been avoided by more diligent editing. At the next level, each system is analysed in ter ms of efficiency, but the concluding chapter contains no attempt to compare and contrast them on the parameter of efficiency, or any of the other three dimensions of the framework. It would have been useful to have a concluding section on each of the four key dimensions of the framework. Finally, the author’ infor med opinions would have s been useful, even with the caveat that different mechanisms and systems suit different political, cultural and economic settings. In conclusion, Public and Private Roles in Health Care Systems is a helpful reference manual for an yone seeking a short, sharp description of health reform in seven OECD countries during the 1980s and 1990s. It will be particularly useful in health economics courses and in courses that compare contemporary health care systems. native to the vexed limits to claims of any evidence-based knowledge that do not realise the y are contingent, contextualised, constr uctivist and temporal. Richard Winter and Carol Munn-Giddings have been leading theorist-practitioners in the UK over a period spanning three decades. They have produced a book that translates well to the Australian context, where it should fur ther illuminate action research in health and human services, as did Robin McTaggar t and Stephen Kemmis’ Action Research Planner in education and the texts of Ortrun Zuber-Sker rit in business/management. There are 11 interestingly written accounts of small-scale health and social care action research projects, ranging from developing innovative nursing practice (e.g. bedside handovers) or in child protection (e.g. assisting child witnesses), through to urban regeneration, examining the positive experiences of black social workers, and consumer research (in mental health and cancer self help). They are contributed by experienced and sometimes key players in their f ields, and illuminate in var ying ways different action research lear ning and guiding principles to date. These include: the business of involving ever yone who is relevant; the implications of working further afield as the systemic nature of issues expands who is ‘relevant’; the need for emotional/peer support to any involved in transforming practice; the signif icance of facilitation skills and e xperience and how best to position this task; the extent of resources and care needed to enable people to speak to each other across silencing disparities of power; the connections between the ‘personal’ and the work problem at hand; the relative simplicity and do-ability of small-scale inquiry; the problems of goal displacement if action research is the aim rather than being a means to address a substantive issue; and the breakthroughs possible when it is done well. In Part 3, Richard Winter publishes his own (action research course notes) teaching about how to go about undertaking an action research project. Part 4 provides a coherent and succinct theoretical justification that deconstructs its controversial nature as stemming from the politically equalising nature of a discourse that admits various stakeholders’ knowledge as important (in the face of other discourses constr uing them as not). This formulation goes beyond the potential dead-end of inter pretive relativism per se, or the potential idealism from an epistemology that sees any knowledge as possible or unconstrained by an at least (and non-positivist) implied or assumed (I prefer ‘agreed’) but always fallible ‘reality’ (drawing on the work of Bhaskar), and situates action research instead within ‘critical realism’, described with commendable clarity and elegance. This is a jewel of the international action research literature that may be ver y useful for existing action researchers as well as those teaching or enrolled in research courses. It would also be worthy of the attention of any general health and human services researchers (including practitioners and consumers) interested in thinking fur ther about their own practice. A Handbook for Action Research in Health and Social Care By Richard Winter and Carol Munn-Giddings. Routledge: UK, 2001. 281 pages, paperback. ISBN 0 415 22484 5 Reviewed by Yoland Wadsworth Institute for Social Research, Swinburne University of Technology How marvellously liberating to read a newly published book that is nigh identical to that which one is in the middle of writing! Liberating because the authors have done such a v ery satisfying job of it (and also because I now don’t have to cover this ter ritory). The f irst 62 pages of this book alone represent a readable and concise state-of-the-art scan across what is a very large ter ritor y (I imagine it may go straight into readers’ packs). This particular book sits within a recent burgeoning literature on action research that, in turn, reflects a growing coherence and conf idence among practitioners of an epistemology that has benefited from both constant contestation by the (moder n) mainstream scientific discourse and from the mutual support and discourse-constr uction from within its own fast-g rowing ‘community of science’. It is a paradigm that senses its time has come, given its peculiar suitedness to a complex postmodern world of multiple viewpoints, multiple realities and contested desires for a variously ‘better world’. With its offer of a non-violent, democratised and systemic approach to hearing from ‘the multitude of counsellors’ (that’s citizens, not parliamentary representatives!), it holds out an alter- 2002 VOL. 26 NO . 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Book Reviews Researching Health Promotion By J. Watson and S. Platt (eds). Routledge: UK 2001. 279 pages, paperback. ISBN 0 415 21591 9 Reviewed by Marilyn Wise Australian Centre for Health Promotion, New South Wales Researching health promotion is a hot topic in the field. There are many signif icant issues to address if there is to be improvement in the relationships between research, policy and practice. Some of these include the need for more systematic, purposive development of theor y, and the more systematic transfer of research f indings into health and public health policy. The evidence base has been growing, but it lags behind our understanding of social and economic determinants of health, and behind knowledge of the components of effective or quality inter ventions. The tools developed to assist in guiding evidence-based practice have led to ‘conflation of the effectiveness of an intervention with the effectiveness or ‘quality’ of its evaluation’.1 This book promises to ‘make a significant contribution to ongoing epistemological, theoretical and methodological debates in health promotion research’, advocates the better use of theory to guide research and practice, and stresses the need for greater theory development. It promises to give practitioners, researchers and policy makers new insights into the challenges for health promotion research and to provide examples of ‘good practice’. The concept of the book is excellent. Divided into three sections, it opens with discussion of key philosophical, theoretical, conceptual and practical challenges for contemporary health promotion and research – connecting research with policy and practice, repositioning health promotion as a focus of policy upstream, integrating environmental sustainability into the health promotion agenda, and the use of a more sophisticated theoretical approach to promoting health-related lifestyles. Section two raises methodological challenges, beginning with an in-depth discussion of postmoder nism and health promotion. This is followed by two examples of the use of different research methods to guide and suppor t intervention design, implementation and evaluation and an exploration of the contribution of economic theory and research to health promotion. Section three includes examples of good practice – that is, of research integrated with practice on a range of issues and in different settings and population g roups. However, despite some ver y good chapters, the book does not deliver on its promise. There is no analysis that links the strategic and theoretical challenges and methodological issues raised in the first two sections with the examples of good practice. It reads, therefore, more as a series of interesting, b ut unconnected papers that would be more accessible to the audiences through peerreviewed literature. There is no discussion of the ways in which these examples illustrate, specifically, ideas raised in the earlier sections. This is disappointing, because the individual examples do appear to be well-designed and implemented projects that integrate research with intervention (for the most part). There is a relatively high level of detail provided about the relationship between research and program development and design and about the interventions themselves. The examples have been written for readers interested in the quality of interventions as well as in the quality of research. In this sense, it is refreshing to find a focus on intervention research, as well as evaluation. That makes it all the more disappointing that none of the projects presented in these chapters addresses social or economic determinants of health, few used social or organisational theory to assist in program design or implementation, all but one described levels of risk only in individuals and, as a consequence, those that presented evaluations used only outcome measures of individual behaviour change. In all, there is no analysis of the programs or of the research in relation to the fresh thinking and methodological challenges that were posed in the opening sections of the book. The section on good practice serves, in fact, to bring into even clearer focus the gap that exists between the cur rent research base and what is needed in terms of theory, methods, polic y and practice if it is going to be possible to address the significant challenges to population health that have been identif ied already. For teachers wanting case studies of well-designed research linked to program design and deliver y (albeit individual behaviour-change programs), the book offers some good examples. For researchers looking to expand the range of theory and research methods that might be used in health promotion research design, there are some useful ideas. For practitioners seeking benchmarks of good practice, it does provide some e xamples. For policy makers, the chapters on strategic and methodological challenges pose some useful questions. But for those looking for inspiration and guidance on the application of an expanded range of research methods (and theory) to guide and support action to address the major challenges to the health of populations now and in the future, the book is not recommended. Reference 1. Watson J, Platt S. Connecting policy and practice: the challenge for health promotion research. In: Watson J, Platt S, editors. Researching Health Promotion. London: Routledge, 2000. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 26 NO. 2 Book Reviews Community Informatics: Shaping Computer-Mediated Social Relations By L. Keeble and B.L. Loader (eds). Routledge: UK, 2001. 388 pages, paperback. ISBN 0 415 23112 4 Reviewed by Chris Peterson School of Public Health, La Trobe University Victoria , This book contains 19 chapters, contrib uted from a conference in 2000 organised by the Community Informatics Research and Applications Unit, University of Teesside, UK. It is a collection of papers by practitioners, academics and other experts that debate the ways in which information technology can effect, develop and transform various aspects of community relations. The edited papers focus on community informatics, which the editors point out is a field of study for investigating cultural and social factors that shape information and communication technology and the effects of this technology on community development. It is a mixture of practical applications of the technologies and of concepts relevant to understanding just how the technologies affect several community aspects, including sense of spatial relations, time and distance, and community organisation. This book is organised into four sections: community infor matics as place and space; the experience of community infor matics; electronic empower ment and surveillance; and polic y implications of community informatics. There are some excellent chapters that introduce important advanced technology and community concepts. These traverse a range from theoretical discourse to ver y practical appraisals of projects and experiments in the role technology has for developing community relations. One of the introductory chapters, on physical place and cyberspace, looks at the role of the Inter net and other advanced technologies in shaping spatial relations in the community. The authors conclude, among other outcomes, that at present the mobile phone offers a g reater creative oppor tunity to exploring spatial relations in the community than the Internet. However, the author creatively evaluates the Internet for its impact on community formation and organisation. Another chapter considers the important topic of the development of self help and support g roups through the use of IT, and provides some useful case material to show how practices such as computerassisted social suppor t can be a ver y effective. It was pleasing to see chapters adopting a critical perspective on women, the community and IT, and a par ticularly benef icial, critical commentary made on male surveillance of female privacy in the use of close-circuit TV systems. One useful and welldeveloped chapter identifies and critically reviews a number of theoretical perspectives in developing a perspective on the contribution of advanced technology to community development and empower ment. In addition, there are a number of discussions in different chapters on social capital as enhanced by the Internet and other advanced technologies. This book is an exciting read, but not altogether easy. I felt there was a need for further discussion in the f irst chapter, by the editors, to point out some key issues in the use of advanced technologies and interfaces between the technology and communities of people. This may have taken the form of identifying some issues such as the effects of technophobia and age on community acceptance of IT, and an evaluation of power relations between technologists – who often drive Internet and advanced technology development – and the extent to which new technologies need to be meshed with satisfying human needs across a range of perspectives, including social, emotional and psychological. This collection contains a small glossary. Although this is useful, it could have contained the large list of abbreviations that occur red in the text, plus full descriptions. This is not a book for everyone; it is more for those who specialise in infor mation technology and/or community relations, and for this readership the book will enhance the debate on community infor matics. For a wider readership, the book could have been more focused on defining concepts and led the reader through a theoretically driven discourse, building concepts along the way. The book covers a lot of g round and requires some reasonable understanding of advanced technology to gain maximum benefits. However, it offers some exciting discussions of front-line developments in the area from across the world and should stimulate some creative solutions to community development. 2002 VOL. 26 NO . 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Book Reviews Home truths about domestic violence: feminist influences on policy and practice, a reader By Jalna Hanmer and Catherine Itzin (eds) with Sheila Quaid and Debra Wigglesworth. Routledge: UK, 2001. 408 pages, paperback. ISBN 0 415 24157 X Reviewed by Angela Taft Centre for the Study of Mothers’ & Children’s Health, La Trobe University Victoria , Ann Flitcraft argued, in an article in a 1992 issue of the Journal of the American Medical Association , that the epidemiology of rape, physical and sexual assaults in marital, cohabiting and dating relationships and long-term effects of childhood sexual abuse reveals women’s vulnerability to abuse across the lifespan.1 The continuing problem, concludes Catherine Itzen in this new, largely British reader, is degendered language and the absence of ‘the violent male’ in domestic violence policy. This is an insurmountable obstacle, she argues, to domestic violence prevention. All other policies (aid to women through refuges, and housing, multi-agency for ums, police domestic violence units and legal sanctions) can be regarded as damage limitation and harm minimisation policies. Itzen’s critical and pessimistic over view of domestic violence policy directions in the f inal chapter of this book is cautionary and relevant to an Australian context. This new comprehensive polic y reader is aimed at both academics and multi-disciplinary professionals, teachers and students (including those in health and welfare) w ho may either manage or provide care for victims, perpetrators and their children. The book aims to provide a combination of feminist theory of violence against women together with a historical perspective on how research and activism has led to shifts in both the understanding of, and responses to, violence against women, men w ho use violence and, more recently, their children. This reflective re-evaluation of policy and practice seeks to provide a context for change both in the UK and more broadly in the global agenda. The book is loosely str uctured, variable in quality and draws together new and previously pub lished British research on domestic violence policy and practice. It illustrates the concept of Flitcraft’ continuum and the har m minimisation practices, which s Itzen critiques. The two of 20 chapters from American leaders in their field provide useful contrasts to the British contributions. For those with an interest in critical analysis of domestic violence policy and practice, this book provides a useful (and updated) comparison with McGregor and Hopkin’ excellent 1991 account s of Australian polic y development, Working for change: the movement against domestic violence.3 A more health-system-specif ic analysis of policy and practice can be found in Stark and Flitcraft’ s 1996 book Women at Risk. 2 Unlike the 1991 Australian account, Home Truths analyses the trends in responses to children and evaluations of American and British responses to men who use violence. These latter chapters conclude, as Itzen does, that men’s behaviour change programs are somewhat effective only for the men arrested and convicted. This is a very small proportion of those abusive to women and unlikely to change, says Itzen, without concerted intervention by the state. For sociologists or policy analysts, I would single out the contribution of Pragna Patel, a Kenyan Indian Hindu immig rant woman, who thoughtfully examines the intersections of violence, gender, race and class in chapter 10. This chapter moves in an intelligent analytic flow from her own identity crisis to the collective actions against male violence of the Southall Black Sisters and their campaign to free Kiranjit Aluhwahlia, jailed for the murder of her violent husband. From here, Patel probes the relations between the state and family as it applies to black and immigrant f amilies, and moves to a spirited critique of multi-culturalism and religious fundamentalism, gender and violence. Her analysis is illustrated by her involvement in progressive alliances both within Britain and between Britain and India, and together with Amina Mama’s study (Chapter 3) provides considerable insight into the struggles for justice and suppor t by black and immigrant women in racist and se xist cultures. For health and welfare policy-makers and practitioners, the book’ interest lies in those chapters providing detailed reflection s and evaluation of overseas strategies. This includes programs for children in refuges and child protection services, analyses of EMERGE, a founding men’s behaviour change program in the US, new UK evaluations of men’ programs by the Dobashes and s chapters on developing multi-agency responses. For those interested in Australian policy and practices towards victimised women, children and abusive men, and an e valuation of the ACT Interagency Family Violence Intervention Program, gover nment funded reports can be downloaded via the Office for the Status of W omen’s Par tnerships Against Domestic Violence website at http:/ /www.padv.dpmc.gov.au/ This book is recommended for public health academics, policymakers and practitioners interested in women’ policy iss sues. It serves as a reminder of the importance of engendering health policy and provides useful comparisons with Australian domestic violence policy and practice. References 1. Flitcraft A. Violence, v alues and gender. J Am Med Assoc 1992; 267:3194-5. 2. Stark E, Flitcraft A. Women at Risk: Domestic Violence and Women’s Health. Califor nia: Sage, 1996. p. 264. 3. McGregor H, Hopkins A. Working for Change: The Movement Against Domestic Violence. Sydney: Allen and Unwin, 1991. p. 150. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 26 NO. 2 Book Reviews Anxiety in a risk society By Iain Wilkinson. Routledge: UK, 2001. 165 pages, paperback. ISBN 0 415 22681 3 X Reviewed by Brendan Gibson Population Health Division, Commonwealth Depar tment of Health and Ageing Anxiety in a risk society aims to make anxiety a focus of sociological inquiry. This is a promising new angle for the sociology of risk, a literature that grew rapidly in the 1990s. By focusing on anxiety, the back cover says, ‘. . . a critical vantage point can be gained from which to attempt to answer the question: Are we more anxious because we are more risk conscious?’ This is an important question because of the burden of disease associated with mental illness and its projected increase. The book’s primary audience appears to be social scientists with an interest in mental health and the social determinants of health. The jour ney to the promised vantage point is in two parts. The first discusses anxiety in theoretical and empirical terms and reviews the psychological literature on ways of coping with anxiety. It chronicles the rise of the view that the modern age is an ‘age of anxiety’. While Wilkinson pays homage to sociology’s holy trinity of Marx, Durkheim and Weber, he gives Freud the primary role of ar ticulating the importance of anxiety in the modern world. He relies on Eric Fromm and Karen Horney, two mid20th century critical theorists, to make a connection between the individual experience of anxiety and rapid social change. In particular, Wilkinson connects the rise in anxiety with the demise of traditional values, beliefs and cultural institutions. The central thesis of the first section is that those who deal best with the anxieties of the modern world are those who have the cultural resources to give meaning to uncertainty and catastrophe. These resources are unequally distributed throughout society and lead to social inequalities in mental health problems. Although Wilkinson is keen to avoid the criticism that this thesis is built on ‘golden ageism’ – a belief that once upon a time and in some societies, humans lived happil y ever after – he does not put this criticism entirely to rest. The second par t of the book discusses the relationship between risk consciousness and anxiety. Wilkinson re views the histor y of the semantics of risk and theories of risk consciousness, particularly that of Ulrich Beck and Mary Douglas. He argues that Beck sees an increasingly hazardous world giving rise to an increasing level of risk consciousness and, perhaps, a reflexi ve capacity for positive social change. He argues that Douglas provides an opposing interpretation. Risk consciousness is the result of a desire for social solidarity in the f ace of perceived threats and is likely to lead to social conser vatism. Wilkinson’s promised ‘vantage point’ on this debate is that it is best seen as a politically motivated exercise that has resulted in little more than ‘castles in the air’. He argues that a focus on anxiety is the best way forward and that this should be linked to empirical work on the actual experience of the problems associated with anxiety. My assessment is that Wilkinson will f ind this ‘vantage point’ hard to hold and that he will not be rushed with disciples. One problem is that his treatment of the work of Beck, Douglas and others is too thin to sustain his savage critique. The major problem, however, is the strength of his alternative formulation. The lack of clarity around the concept of anxiety is most problematic. The closest we come to a def inition is as follows: ‘The term anxiety is a symbolic for m of culture representing a state of mind and emotion by which we are made to be convinced that we are in a situation of threatening uncertainty.’ (p. 17) I do not understand this sentence. What is clear, however, is that Wilkinson sees anxiety as the product of social forces beyond the control of the individual. This does not sit well with other parts of the book that emphasise individual agency. Wilkinson appears to view anxiety as a multidimensional concept that has both an individual as well as a social component. At times he describes it in terms of its difference to fear, but at other times he suggests there is a comple x relationship between anxiety and knowledge of fearful situations. Sometimes anxiety is primarily to do with meaning or the loss of meaning. At other times it is related to the sense of being overwhelmed and powerless, but Wilkinson does not dif ferentiate it clearly from depression. He wants to hold on to the idea that anxiety has a ‘quality of indefiniteness’ but also expects assent to grand claims such as ‘It is now a matter of sociological common sense to identify ourselves as li ving through a period of acute insecurity and high anxiety.’ (p 42) Getting a handle on the subtleties of Wilkinson’ s view of anxiety is made more difficult by an inadequate index that has just one entry for the term anxiety. To be more successful, this book needed to be much clearer about the concept of anxiety and make better sense of the relationship between individual agency and social structure. 2002 VOL. 26 NO . 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Book Reviews Forgetting compliance: Aboriginal health and medical culture By Kim Humphrey and Tar un Weeramanthri with Joseph Fitz. Northern Territory University Press, 2001. 122 pages, paperback. RRP $30. ISBN 1 876248 59 9 Reviewed by George Sansbury Faculty of Law and Management, La Trobe University Reviewed by Rhonda Galbally www .ourcomm unity.com.au This book addresses factors affecting patient compliance/noncompliance with ser vices and systems in the area of Aboriginal health. Its stated intent is to question effor ts to improve compliance in the Aboriginal context from the point of view of the nonAboriginal health provider’s systems and org anisational frameworks. In pursuit of this, the authors critically analyse the concept of ‘compliance’ and conclude that it is an inappropriate concept for several reasons. First, it represents a predominantly Western view of health and, second, it assumes that Western health systems and professionals have a superior legitimacy to alternative systems and beliefs. The book provides a succinct overview of the genesis and historical use of the concept of compliance and critically discusses the situation in Third World and indigenous populations. Review of the research data leads the authors to conclude that health professionals need to develop the ability to think about compliance beyond the conventional medical model. They recommend that such an approach be under taken with the aim of ‘critiquing and transforming institutional arrangements, organisational forms and decision-making structures’ (page 104) and to ‘confront provision and uptake issues beyond the bio-medical and clinical frame in terms of actively and vocally connecting improved health status and treatment outcomes to issues of socio-economic well-being and social justice’. (page 104) The authors choose to emphasise the first of these, i.e. the need to critique and transform institutional and organisational ar rangements, believing, reasonably, that this is most realistically within the ability of health professionals to affect. To this end the material concentrates on the institutional structure and process of health deliver y and provides a critique of the inherent ethnocentrism of professional health service to indigenous communities (i.e. within a Western biomedical context). From this, its intended audience of health providers, administrators and policy makers will gain an incisive insight into the issues concerning the inappropriateness of Western models to indigenous and non-indigenous health care alike. This approach echoes that of previous writing on indigenous policy and ser vice provision in that it places the locus of control and meaning outside of Western culture and institutions (Coombes, 1978).1 Although tackling social inequity is understandably considered by the authors to be an unrealistic goal for health professionals to take on alone, it is still of critical importance that health care enjoins with movements to fight for equity, justice and human rights. The book is timely and useful in this demand for Indigenous, community management and control of service deliver y in Aboriginal health. Indeed, this is a core issue, not only for Indigenous health care but also for efficacious outcomes in Western health care. Such emphasis – on transferring the dominant perspective to recipient g roups and communities – is echoed in research in social epidemiology w hich emphasises the dominant , role in community health of the impact of socio-economic status, community control and social justice factors (Syme, Marmot and Heyman 2000). 2 Thus, it would seem that the prevailing institutional and cultural paradigms need to be questioned with regard to all community health provision and not just that of Indigenous health. Therefore, the emphasis upon these institutional and cultural issues by the authors is of particular impor tance since any change of institutional paradigm has, as a prerequisite, the need for changes in values and perspectives on the part of the health service professional. In addressing the issue of perspective, the book is timely since health research suggests that a reconciliation of health service provision (in a Western, or any other, cultural model) to these factors is now required. Forgetting Compliance provides a focus for rethinking directions in health provision.

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Jan 1, 2002

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