1928 Book Reviews

performance and efficiency of such organizations, particu- larly the proprietary chains. (His conclusions, however, may be quite sensitive to the method of computing the costs of capital or adjusting for the effects of infllation.) He also raises the issue of “cream-skimming” for paying patients. (One wonders whether this is a general consequence of contrained funds and heightened pressures for cost control that is independent of organizational form.) But the decision-making status ‘of physicians and the fate of the doctor-patient relation in such organizations are not really explored. Starr merely concedes that “Doctors continue to hold strategic positions through their established relations with both patients and hospitals”.

While economists might look to new, previously un- realized economies of sale to explain the emergence of large scale oragnizations, Starr sees little or no evidence for such economies. Group practice, he notes in passing, has only a small cost advantage over solo practice. The vertically integrated systems, particularly “health maintenance org- anizations”, apparently reduce hospitalizaton rates. Other- wise, Starr concludes, large scale enterprise is merely an adaptation to an incentive system that has already been skewed. Little or no reference is made to extraordinary changes in medical technology, medical information sys- tems and the marketing of medical care services.

Starr himself appears quite ambivalent about the fore- casted loss of autonomy. On the one hand, the emerging dominance of large scale organizations in medical care will finally bring to maturity a system that was arrested in its early development 50 years ago. On the other hand, he suggests, such “corporate” enterprises are not likely to have the same concerns for equity that might prevail under comprehensive state intervention. In the end, one is left with the sense that Starr has not gone far enough. Rapid changes in science and technology have transformed the special relation between doctor and patient that prevails in Western culture. American institutions have made their own unique adaptations to such rapid changes. But can the physician still play the role of paladin for his patient in the new, emerging hierarchical organizations? How can physic- ian incentives be restructured to reflect both the organiza- tion’s efficiency goals and the humane dicta of plain doctoring? These are the central questions.

Still, Starr has produced a comprehensive and readable history of American medicine. The volume will no doubt last as a major accomplishment.

Massachusetts General Hospital Boston, MA. U.S.A.

JEFFREY E. HARRIS

Birth in Four Cultures, by BRIGITTE JORDAN. Eden Press Women’s Publications, Montreal, 1980. 109 pp. 17 Plates

Thumbing through this slim volume may initially discourage the lay or strictly medical reader from completely reading Jordan’s work. With chapter headings like “A Biosocial Framework for the Crosscultural Comparison of Childbirth Practices” and “The Crosscultural Comparison of Birthing Systems: Towards a Biosocial Analysis”, one might expect a dry, jargon-filled display of data, impossible to relate to consumer issues or to medical practice. However, the reader willing to push on past the titles will be rewarded with an informative, compact and useful work.

Brigitte Jordan won the 1980 Margeret Mead Award for her studies of the socio-cultural aspects of childbearing. Birth In Four Cultures outlines her work in the crosscultural evaluation of childbirth, provides the details of her observations, and proposes several ways in which her data might be used in effecting change in the birthing systems of both underdeveloped and developed nations. The usefulness of such a study is three-fold. As childbirth is physio- logically the same process for women of all cultures, the way in which a culture handles birth gives significant clues into

the structure of that society. Secondly, as childbirth is usually “women’s business”, a study of crosscultural methods of childbirth “cannot but improve and broaden our apprecia- tion of the organization of female networks, interests, and strategies” (p. 4). Thirdly, all cultures are prone to see their methods as ‘superior’, and so remain very uninformed about other methods of handling birth. A crosscultural comparison might then afford several cultures a view into other ways of managing the childbirth experience.

Jordan spends the first quarter of her work detailing the reasons for the study and her choice of cultures-an indepth view of childbirth in the Mexican Yucatan Mayan Indians, along with briefer comparative looks at childbirth in the United States, Holland and Sweden. She spent most of her data gathering time in the Yucatan; the details of this birthing system make up another quarter of her book. Through notetaking and videotape, Jordan and her assistant captured the form and structure of what might initially seem a very informal system. Prenatal care is in- frequent, birth is at home and support is provided by many family members. However, elements of the system, such as prenatal massage, the role of the support persons, and the post partum rituals, are highly structured.

The third section of Birth In Four Cultures compares the Yucatan practices with those in the United States, Holland and Sweden. Jordan underlines the fact that she is concerned only with the traditional U.S. hospital birth (as opposed to birthing rooms and birth centers) since that hospital setting represents the norm. She reminds us that, in stable systems, every set of practices within the system is seen as appropriate. Therefore, crosscultural examination of birth must include social-ecological factors as well as medical- physiologic factors. Indeed, it is sometimes difficult to separate actions based on physical needs from those based on social considerations. For example, Jordan feels that in the traditional U.S. delivery room, the climate of rushing, action and intervention that stamps the American mode of delivery might be more a function of the social awkwardness of standing around than any physiologic need to hurry the delivery.

Jordan draws her crosscultural comparisons most clearly when she deals with the issue of pain. She establishes that pain is present in any birth, in any culture, and the “notion that ‘primitive’ birth is easier than ‘civilised’ birth is clearly false” (p. 36). In the Yucatan, suffering is viewed as transient and normal, not to be ‘cured’. In Holland, pain medications arenot widely used, even in the hospital setting. As Dutch mothers have no expectations of receiving narcoticrelief, they take more responsibility for learning how to cope without it.

In Sweden, analgesia and anesthesia are used very liberally, often administered by the midwife in the hospital setting. Mothers are adequately educated about the medica- tions, their benefits and side effects. Decisions for pain relief are then left to the mother. In contrast, American women, laboring within a medical system which prides itself on pain relief, indeed seem to suffer a great deal. One reason for this increased display of suffering, Jordan suggests, is that in the United States the medical and nursing staff are the caretakers of pain relief drugs, and women are in a position of having to convince the staff, usually by acting out their pain, that they are in sufficient distress to warrant pharmaceutical intervention.

What applicability do her observations have for institution of change in obstetric systems worldwide? First. practioners must realize that all systems have a sense of “moral required- ness” about their way of doing birth. Additionally, all systems justify themselves from within. This is all right, Jordan maintains, as long as the justifications do not become elevated to “scientific criteria” which claim universal applicability. When dealing with another culture, one must separate that which is appropriate medical intervention from that which might be inappropriate cultural intervention.

Book Reviews 1929

Traditionally, local systems have been upgraded to Western ideals medically, disregarding the importance of integrating prevalent socio-cultural mechanisms. Perhaps, Jordan suggests, medical personnel may also, in some instances, need to upgrade socio-culturally so that new information may be more appropriately used. For example, in the Yucatan, education of practitioners must employ hands-on “doing”, otherwise all that is changed is ways of talking about birth, not ways of managing birth. Concrete steps in assessing the need for change in a birthing system involve observation and classificaton of practices into those which are beneficial (to be encouraged), harmless (to be ignored), harmful (to be modified) and those practices about which the examiner is uncertain (to be left alone until further observation occurs).

Basically, Jordan’s work was well-organized, systematic- ally presented, and objective. However, several errors in the section on American birth were jarring and left this reader hoping that she was more accurate in her observations of other systems. For example, she stated that “once the baby is born, there is no place for the obstetrician to put it as long as it is attached to the placenta. This awkward situation is resolved by cutting the cord immediately, a practice which results in the infant not getting about 25% of the blood supply that is its due” (p. 61). In my experience, the continuing debate over when to cut the cord rages independ- ently from lack of, or presence of, a place to put the baby. An additional weak point of the book’s production was the overall poor quality of the photographs. Still, this practi- tioner found Birth In Four Cultures useful in re-examining the approach to laboring mothers and analgesia in my hospital setting, and the principles of how systems change would be beneficial to anyone who works for change in birthing systems in this country.

South Sunflower County Hospiral BARBARA PRICHARD Zndianola, MS, U.S.A.

Medical Choice in a Mexican Village, by JAMES CLAY YOUNG. Rutgers University Press, New Brunswick, NJ. 1981. 223 pp. $19.50

The influence of culture on the choice of medical treatment has been explored in the anthropologic literature and more recently has been the subject of medical investigation. James Clay Young provides a new and provocative look at the nexus between culture and therapeutic choice in a pluralistic setti,ng.

In Medical Choice in a Mexican Village, Young describes the realities of health care in San Francisco Pichataro, a Sierra Tarascan town in the Mexican state of MichoacBn. With his wife Linda Garro, Young lived in the town for over a year, and carefully developed a model to account for the medical treatment choices made by Pichatarerios. They conclude that treatment choice was largely influenced by economic rather than cultural constraints.

Young chose a decision-making analysis to develop his treatment choice model. As Young explains, much of the past an has ten ?

opologic research using a correlational approach ed to dichotomize medical choice as Western vs

traditional, a distinction not necessarily made in the minds of the medical consumers themselves. While varied con- siderations may lead to the same observable outcome through very different (but unmeasured) cognitive processes, conclusions drawn from such research cannot be independ- ently tested since they may reflect the investigator’s own research bias. A decision-making study, on the other hand, begins with the premise that there is a common set of standards for making a choice; these standards for selection are defined and the principles are formalized into a descriptive model that can be critically tested for its validity. Young’s model, which he carefully develops and

outlines throughout the book so that it can be understood by the statistical novice, accounts for 91% of the treatment decisions analyzed.

The text itself is readable and well organized. Young is careful to explain data collection and analysis, opening himself to close scrutiny of his investigative methodologies. The opening chapters give a thorough background of the town and region; the following section elaborates specific illness beliefs of the area, outlining body parts and body functioning as perceived by the Pichatarefios in both health and illness. This section, including a careful sum- mary of data retrieval methods, is particularly well done and provides thenecessary context for the subsequent descriptive analysis. Final chapters develop and analyze the model for therapeutic choice. The text is followed by a series of appendices which further elaborate sample collection and analysis. Extensive footnotes to the main body of the text are consolidated at the end of the book, as is an expansive bibliography. A thoughtful touch of the author is a glossary of Spanish terms used throughout the text.

Young found that the seriousness of an illness or symptom was the most important factor in the selection of a therapeutic modality. Using data from extensive interview- ing, Young divided illnesses and symptoms into three separate categories : non-serious, moderately serious or gravely serious, and then ordered these in a cluster analysis to yield two consistent patterns of treatment choice, “probability of cure ordered” or “cost ordered”, depending on the gravity of the illness and the economic means available to the patient.

Pichatareiios followed a pragmatic approach to illness and healing, seeking the lowest cost alternative that could reasonably offer a cure. A physician was seen as having the higher probabilitytof cure but was also the most costly and inaccessible (the closest Western-trained physician at the time of the study was an hour bus ride from the town). lf an illness was not considered life-threatening, alternative and less costly treatment options were ordered on the basis of probability of cure. The physician would be consulted first, however, if an illness were considered life-threatening or grave; thus economic constraints limited the Pichat- arefios’ use of available Western medical facilities for all but the .nost serious illnesses.

Young’s conclusions do not support the view that traditional beliefs in themselves inhibit the use of Western facilities. In fact, using his model, Young could show very few cases where a traditional healer would be chosen in preference to a Western-trained physician.

As Young puts it, “we see a people with. a genuine enthusiasm for. modern medical treatment, but who are at the same time frequently denied full access to such services. (The) traditional system of medical beliefs and practices, which remains full and vigorous, and the continuing use of and role for native curers. . and marginal medical personnel. . may be seen as aspects of the community’s ongoing adaptation to this position of economic and social marginality in relation to the larger Mexican society”.

The solution for the problems of limited access cannot come from the community itself. for changing attitudes or improving health education will not necessarily create the socioeconomic change necessary to upgrade the population in the economic system. If it is the restricted access to Western health care which is the limiting factor in the utilization of Western health facilities, then the burden must fall on the state to improve access and distribute health care resources in an equitable manner. Young feels the primary role of the applied anthropologist in this setting is not to advise medical personnel of the best ways of over- coming “cultural peculiarities” inhibiting the acceptance of Western medical care, but rather to insure that the com- munity has genuinely available “its fair share of whatever medical services its government is capable of providing”.