Book Reviews 1473

than changing it, Desire and Craving, in the end, is a REFERENCES powerful argument for therapeutic modalities that are culturally (and sub-culturally) specific and sensitive. 1. Fingarette H. Heavy Drinking: The Myth of Alcoholism

as a Disease. University of California Press, Berkeley, Department of Anthropology SUNY at Buffalo Buffalo, NY 14261 U.S.A.

DONALD POLL~CK 1988. 2. Gefou-Madianou D. Alcohol, Gender, and Culture.

Routledge, New York, 1992.

AU God’s Mistakes: Gene& Counselling in a Paediatric Hospital, by CHARLES L. BOSK. University of Chicago Press, Chicago, 1992.

This book marks a departure from most previous studies of genetic counselling. Rather than focusing on the clinical encounter, it describes the day-to-day routine of a team of counsellors, their practice and personalities and how these bear upon their everyday activities.

The research was carried out in an American paediatric hospital in the period 1976 to 1980. It shows how the counsellors function as a professional group, and how, as individuals, they contribute to tension and disagreements. It shows the public face of genetic counselhng, that experi- enced by those using the service, but also the backstage of departmental politics, personal relationships and, at times, subjective interpretation of risk.

Through observation of the team Bosk comes to examine the nature of genetic counselling itself. He looks at several of the key features of the process: interpretation of risk, directive and non-directive counselling, the power relation- ship between those giving and those receiving the infor- mation, and the meaning of that information for counsellees. Through case studies we see the entry of parents into the world of genetic disorders and some of the difficulties involved in giving information about reproduc- tive risk.

An example of such a case study is that of a couple due to be counselled about the chances of a recurrence of tuberous sclerosis, a dominantly inherited and variable disorder. Despite heavy disputation between the team leader and the other counsellors over whether there is a new mutation or whether the father is in fact mildly affected, the team leader intends to counsel the couple that they are at no increased risk of recurrence.. Various attempts at disua- sion are made by horrified colleagues. Ultimately the couple are told that “if they had a second child with tuberous sclerosis, they would be written up in medical textbooks”. This example places information-giving in a larger context of subjectivity and departmental hierarchy as well as provid- ing human interest.

Bosk feels that too great an emphasis is placed on presentation of statistics or risk figures to counsel&s. He sees this as a product of rigid adherence to non-directive- ness, resulting in a failure to address the individual concerns of the counsellees. “The counsellors use . the goal of patient autonomy as a ground for patient abandonment.” This is interesting in the light of current debates in the U.K. which focus primarily on the feasibility of the non-directive stance. Whilst many see a departure from the rule of non-directiveness as anathema, Bosk argues that the insis- tence on this approach is taken to extremes and so marks a denial of the emotional needs of the counsellees. Those reading the book who include emotional support and be- reavement counselling as an ordinary part of their relation- ship with counsellees will find a very different representation of the clinical encounter here.

He perceives the role of the counsellor as being con- strained by the insistence upon neutrality. This extends to

relationships with other professionals for whom they provide information for decisions in the treatment (or non-treatment) of affected newborns. Even in these situ- ations he feels that the counsellors maintained the conven- tions of non-directiveness, and despite their expertise, they felt unable to advise on the most appropriate course of action. “They are a virtual Greek chorus commenting upon a tragedy which they are well-placed to observe but power- less to prevent.”

Despite the contribution made to the debate on non-direc- tive counselling, the value of the book is restricted in a number ways.

At times there is some rather forceful criticism of the counsellors. One is often left with the impression that Bosk fluctuates between respect and distaste for these characters. It is not, however, wholly clear that the counsellors them- selves are failing patients, rather that the process stops short at the point of information-giving. It is shown that they have nowhere to refer those needing emotional support, a failure of the system rather than necessarily implying ‘patient abandonment’ or lack of concern on the behalf of the team.

The book describes a largely antiquated situation. The field of human genetics moves too fast for the lapse of so many years between fieldwork and publication not to have ramifications. At the time of the observations major break- throughs, such as the identification of the gene for cystic fibrosis, had not yet been made. In the years that have followed both prenatal diagnosis and predictive testing for late onset disorders have changed dramatically and the situations of many of those reported as case studies are now greatly changed.

Similarly there has been a shift in the professional profile of genetic counsellors. Those described were physicians. Genetic counselling is now largely undertaken by other health professionals. Counsellors are unlikely to have a role in, for example, decisions over the discontinuation of treat- ment of neonates.

The sampling of only one team of counsellors is in- adequate to support an entire book. As many of the incidents in the book pertain to individual characters there is little sense of the extent to which the practice observed can be used to infer practice in genetic counselling in general.

Bosk’s distaste for his task is evident. He is made uncom- fortable in several ways: by the political demands made of him within the department, such as to observe one counsel- lor in order to inform the rest of the team of his practice; by witnessing what he describes as the ‘tragic choices’ made by couples and families affected by genetic disorders, and by his own discomfort and moral qualms with developments in the field of human genetics. Unfortunately this unease permeates the book to an unacceptable degree with too many complaints about his role and apologies for his subjectivity and the inadequacies of the data.

The information presented is interesting and unusual but there are major flaws which undermine the usefulness of the book and of which Bosk seems well aware. Indeed he devotes much of a chapter towards the end of the book to his own perceptions of the shortcomings of the research. The

1474 Book Reviews

book is at times heavy going and over-theorised and per- Centre for Family Research vaded by an image of an author with little relish for the task University of Cambridge in hand. U.K.

CLAIRE SNOWDON

The Health of Adults in the Developing World, by RICHARD G. A. FEACHEM, TORD KJELLSTROM, CHRISTOPHER J. L. MUR- RAY MEAD OVER and MARGARET A. PHILLIPS. Published for the World Bank by Oxford University Press, New York, 1992. 360 pp., $34.95.

In contrast to child health, little is known about the levels, determinants and consequences of adult ill health in devel- oping countries. The conventional wisdom has always been that given the relatively young population age structure in these societies, child health concerns should be of primary importance. In recent years however, increasing attention has been directed towards adult health in the developing world as researchers have begun to recognize that falling fertility rates and increases in life-expectancy have resulted in adults becoming a rapidly expanding part of the popu- lation of most developing nations. Moreover the conse- quences of adult ill-health on child health and survival and overall household economic status and productivity have begun to be more appreciated. This heightened interest in adult health has no doubt been accelerated by the AIDS epidemic which is primarily affecting adults between the ages of 15-59.

This book is thus a very timely and excellent addition to the sparse literature on adult health issues in developing countries. In 350 pages it summarizes (in the context of the developing world) the motivation for studying adult health (Chapter I), the levels, patterns and causes of adult mor- tality and morbidity (Chapters 2 and 3), the consequences of adult ill-health (Chapter 4), current and future determi- nants of adult ill-health (Chapter 5) and finally the emerging agenda for action in adult health (Chapter 6). The authors represent an interdisciplinary group consisting of epidemiol- ogists/public health specialists (Feachem, Kjellstrom and Murray) and economists (Over and Phillips) under the aegis of the World Bank which is sponsoring this publication.

The book makes a number of key points which are worth highlighting:

(i) Adult mortality and morbidity (between the ages of 15 and 60) represent a substantial fraction of ‘avoidable’ health problems suffered by developing countries. The authors pre- sent a number of calculations in an attempt to quantify the burden of avoidable ill-health. These figures need to be interpreted with some caution as they are based on a number of strong assumptions. However the basic point is well taken.

(ii) The ill-health of adults has serious consequences for the individual, his or herfamily, and society. The authors provide a very lucid and comprehensive discussion of the multi- faceted impacts of adult ill-health, acknowledging the fact that much research needs to be done in this area as reliable empirical studies are few and far between. A particular vexing methodological issue in interpreting the association between adult ill-health, income, productivity and health status of other family members, is the possibility of simul- taneous causation.

(iii) The nature, distribution, and trenrls of adult morfality challenge some widely held pre-conceptions. The authors claim that non-communicable diseases and injuries are the

leading causes of adult death in most developing countries. This assertion must be interpreted with some trepidation as data for many high-mortality countries is markedly in- adequate (as the authors themselves acknowledge). Given the lack of reliable data on mortality, summary statements about age and cause-specific death rates must also be viewed tentatively.

(iv) The lack of data on adult ill-health in developing countries is a serious obstacle both for researchers and policy-makers. This a point which is very well taken and is particularly true with regard to morbidity and the conse- quences of ill-health as alluded to above. Research in health is often a low priority for developing countries and is often viewed as a luxury. However as the authors very correctly point out, given the low level of resources available in these societies, health research may be a most cost-effective investment.

(0) Finally, despite inadequacies in the knowledge base of determinants of adult health, enough is known to implement relatively focused and effective intervention strategies. In the concluding chapter of this book, the authors sketch out an agenda for action in which they identify the ten concrete areas worthy of ‘cost-effective’ intervention in the develop- ing world. These include: (i) the withdrawal of resources from inefficient and inequitable Government services for adults; (ii) the cessation of smoking; (iii) making road travel safer; (iv) vaccination against Hepatitis B; (v) making motherhood safer by both encouraging family planning and improving pregnancy related services; (vi) promoting safe sex and treatment of STDs; (vii) improving the case manage- ment of tuberculosis; (viii) increasing cervical cancer screen- ing; (ix) the relief of cancer pain, and (x) the treatment of Diabetes.

While one can debate the basis for the ‘cost-effectiveness’ designation, the above prescriptions are by and large reasonable and sensible.

Overall I really liked this book and found it to be very informative. A distinctive feature of this volume is the synthesis of viewpoints/research from both epidemiol- ogy/public health and economics. This inter-disciplinary approach makes it a particularly valuable reference in the policy debate about health priorities in the developing world. My only quibble about this otherwise excellent book is that it appears somewhat overly technocratic and narrow in its view of health problems and their solutions. The emphasis by design is in the efficient, effective and equitable allocation of health budgets in the pursuit of relatively focused health interventions. Relatively little attention how- ever is given to the larger social context in which health problems arise and,wherein may lie more effective broad- based solutions. The classic example of course is education and its impact on health. One could argue that investments in education and general socio-economic development may be as important as more narrowly focused technocratic solutions.

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