Interpretive Description by Sally Thorne

BOOK AND FILM REVIEWS

Breeding Contempt: The History of Co-erced Sterilization in the United States.Mark A. Largent. New Brunswick, NJ:Rutgers University Press, 2008; x + 213pp.

Anne Line DalsgardAarhus University

Over and over again anthropological re-search has demonstrated that by catego-rizing others as “different,” we safeguardour own moral standpoint as “right.” Fromthe sideline Mark Largent’s argument re-confirms this insight. Largent is a histo-rian of biology, and Breeding Contemptis primarily a thorough historical analy-sis of the different actors and positions inthe movement for and against coerced ster-ilization in the United States in the 20thcentury. In five comprehensive chapters,Largent looks at the role of physicians, bi-ologists, the law, and the Catholic Church.Through biological textbooks, public de-bates, law material, and selected cases takento court, Largent examines the assump-tions and motivations behind this move-ment that led to the coerced sterilization ofmore than 63,000 Americans by the early1960s.

Largent’s aim, however, is not just a re-view of historical data. He explicitly stressestwo points in the book. First, that despitelater times’ characterization of the move-ment for coerced sterilization as eugenic,many operations were carried out for otherreasons than control of genetic material. So-called sexual perverts, chronic masturba-tors, and homosexuals, were castrated, orasexualized, for therapeutic reasons, as wellas because it made them easier to managewithin state institutions. Likewise, the puni-

tive aspect of castrating convicted rapists,child molesters, and men convicted of ho-mosexual activities was a strong argumentfor coerced sterilization by law. In addition,the historical data shows that agitation infavor of compulsory sterilization laws orig-inated long before the coordinated effortsof U.S. biologists. As Largent writes, the bi-ologists arrived quite late into the discus-sion, but they were also among the last toleave.

Largent’s second point is that, regardlessof the movement’s need for scientific legit-imization, the biologists probably gainedmore than the activists from participat-ing in the movement. Through that, theyearned high respect from social and po-litical authorities—and substantial fundingfor their research. The work of two cen-tral figures, Charles Davenport and HarryLaughlin, stands out; Largent describes theirprofessional careers and influence on thedevelopment of U.S. biology. He ends thechapter “Eugenics and the Professional-ization of Amefrican Biology” by notingthat Davenport and colleagues believed thatgood heredity was meaningless without anequally good environment, wherefore theysupported progressive reforms like compul-sory schooling.

Throughout the book, Largent demon-strates that not only has the practice of co-erced sterilization in the United States restedon the “othering” of criminals, rapists, andthe developmentally delayed, turning theminto people who should be denied the rightto reproduce, but also the history writtenregarding this problematic past has itself toa large degree applied the same moral dis-tancing tactics. By casting the advocates ofcoerced sterilization as a few, radical eu-genics supporters, the historical debate has

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shown a strong tendency to avoid any senseof responsibility toward that which tookplace. Likewise, it has overlooked the en-during influence of biological determinismin American society today. Breeding Con-tempt is thus both a review of historicalacts and a confrontation with the contemptthat, according to Largent, later times haveshown the motives behind these acts. AsLargent concludes, “We must rescue theAmerican eugenics movement and the advo-cates of compulsory sterilization laws fromthe dustbin of history—not to celebrate theirprejudices or apologize for their mistakes,but to confront our connection with them”(p. 146).

The book addresses the contribution of aparticular discipline, biology, to the broadersocietal debate on the protection of the na-tion from deviancy and degeneration, andthis discussion seems relevant for schol-ars interested in the cultural constructionof biomedicine as well as medical and bi-ological aspects of citizenship. The bookprovides neither a strong argument againstcoerced sterilization nor an eloquent the-oretical elaboration of the biologizationof citizenship or the link between citizen-ship and reproduction. But it does offerthought-provoking, historically contextual-ized data that allow the reader to reflectand draw his or her own conclusions,which I find a sober and fully justifiablecontribution.

However, although Largent does showthat sterilization has been used to solvecomplex social and personal problems, thereader is never presented with this underly-ing social and personal complexity, and thisis a pity. Exactly because biology has legit-imized the individualization of the problemto be solved, both by proposing the notionof “survival of the fittest” and in divertingattention from our social responsibility forevery citizen’s well-being toward the well-being of the nation through surgery on indi-vidual “degenerated” bodies, it would havebeen interesting if the book had questioneda different perspective. How, for instance,were homosexuals treated if they did notaccept to be castrated? How would the de-

velopmentally disabled bring up a child, ifthey had one, and how were parents withmeager resources in general found lackingin the public’s opinion? In my own researchin Brazil it is clear that idealized (read, mid-dle class) parenthood plays an importantrole when individual women opt for ster-ilization, and values about “proper” par-enting may have been at play, too, in theU.S. sterilizations. The fact that Davenportand colleagues saw nature and nurture asequally important calls into question whatothers’ ideas were regarding education andpersonhood.

Likewise, it would have been interest-ing to know more about global relationsin thought and action. In Denmark, forinstance, in the period 1929–67, 6,000Danes were coerced into sterilization be-cause of their ostensibly lacking intelli-gence and having inherent tendencies todefile and degenerate the genetic qualityof the population. In Denmark as wellas the United States, Nazi Germany hasbeen called to task for this situation, butwhich are the notions of “nation,” “body,”and “citizenship” that lay behind this gen-eral Western line of thought? Such ques-tions are neither raised nor answered inthe book. Perhaps that would have been anunattainable aim. Yet it leaves the readercurious.

As it is, the book will be of relevancefor graduate and undergraduate students aswell as scholars interested in U.S. citizen-ship and the ideological relations betweenprocreation and the nation, both within his-tory and the social sciences. In my opin-ion, to be of real relevance for anthro-pologists the book would need to have amore explicit theoretical framework pro-voking comparison and generalization. Itcan, however, serve as an example—and,in a U.S. context, probably a provocativeone—of the historical construction of thecitizen and its social and outright physicalconsequences. Despite being a little too de-scriptive, Breeding Contempt is a seriousand interesting work that offers many in-sights and material for thought and furtherelaboration.

506 Medical Anthropology Quarterly

Interpretive Description. Sally Thorne.Walnut Creek, CA: Left Coast Press, 2008;272 pp.

Guro HubyUniversity of Edinburgh

This book outlines a particular approach,“interpretive description,” in research toimprove health care. It is written for neo-phyte researchers with a background in(nursing) clinical practice, or for social re-searchers new to qualitative methods in re-search as applied to health care. However,it can usefully be read by more experiencedqualitative researchers to help continuousreflection on our own practice in the chal-lenging, complex, frustrating, and reward-ing task of unraveling the complexities ofhealth care.

The book has its origin in the author’searly experience of “schisms” (p. 23) be-tween researchers who are also health careprofessionals and social scientists weddedto “classic research methods” (p. 18). Forthe first group, the purpose of knowledgecreation is to improve our understanding ofthe dilemmas, challenges, and opportunitiesfaced by individuals who are in some waycaught up in the complexities of ill healthso that we can improve care. For the lattergroup of social scientists, however, accord-ing to the author, research’s aim is “theo-rizing” or progressing a particular theoryabout the relationship between the individ-ual and society, be it the many forms thathuman society can take (“ethnography,”p. 27), the way the articulation of an ill-ness or health care experience is structuredin a particular setting (“grounded theory,”p. 28), or the essence of individual expe-rience (“phenomenology,” p. 29). Thornesuggests that existing qualitative methodsand methodologies have been developedwithin particular schools of thought withdifferent takes on human society, and thatany one of these approaches cannot there-fore produce the kind of clinically relevantknowledge needed to improve complex, on-the-ground practice. She therefore arguesthe case for a distinct methodological ap-

proach, namely “interpretive description,”to meet this need.

I understood the text to make two keypoints regarding the research process, thecombination of which constitutes a good“interpretive description.” The first pointconcerns flexibility. To do research that canaddress issues of health care practice, theresearch has to be designed to grasp andrender intelligible the complexities of thispractice. The researcher will need to designa project that can address the particular is-sue at hand, using the different qualitativeapproaches and tools available. The sec-ond point concerns the rigor and care withwhich a fit-for-purpose project is designed,lest the combination of different approachesand methods produces epistemological andmethodological tangles, which are later dif-ficult to undo.

The text takes the reader through thejourney of a research project that will in theend produce an “interpretive description”of a clinically relevant issue or topic thatcan change practice. The stages of this jour-ney are broadly familiar to any researcher:framing a question, designing a study to ad-dress this question, collecting data, analyz-ing data, and reporting and disseminatingfindings. However, the shape of the journeymight look a bit different from the shapegiven in conventional textbooks in quali-tative research; for example, comparativelylittle space—only one chapter—is devotedto data collection. The text emphasizes theimportance of formulating a research ques-tion, designing a study that can address thisquestion and creating a flexible but rigorousstrategy for implementing the design in real-life health care settings as the foundation ofa high-quality and useful research product.Five chapters are devoted to predata collec-tion processes. Four are given to data anal-ysis, under headings of “Making Sense ofData,” “Conceptualizing Findings,” “Writ-ing Findings,” and “Making Sense ofFindings” (by contextualizing in wider lit-erature). Refreshingly, three chapters aregiven up to a discussion of disseminatingfindings in a way that maximizes impact onpractice.

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The description of the journey is writ-ten for somebody who continually nego-tiates the interface between research andpractice. For example, considerable space isgiven to the discussion of framing a questionfrom clinical practice that can be researchedto yield useful knowledge and novel in-sights. Framing such a question requiresmore work than might be first assumed:It takes the marriage of practical experi-ence, knowledge of the literature(s) of rel-evant fields, and an understanding of theways in which particular phenomena can beaccessed with existing methodological op-tions. Keeping the practitioner self and theresearcher self separate during the negotia-tion of access to the field and data collectionand analysis also is important.

The dual message of flexibility and rigorin designing, undertaking, and communicat-ing findings from a project is key for allresearchers who aspire to address complexissues, no matter how experienced and re-gardless of “applied” or “pure” leanings.The text is aimed at practitioners new to re-search, and I have found it useful already insupervising graduate practitioner studentswho struggle to marry a credible researchproject with a passion and commitment topractical and political questions relating tohealth care. The book is also useful for thosewho consider themselves experienced prac-titioners of research applied to health care,as the way the message is put across is re-freshing and clear and reminds us that eachresearch project is a completely new jour-ney that has to be undertaken with a freshoutlook. Experience in research can help innegotiating the journey, so long as it doesnot make us complacent and tempt us tofall back on familiar and comfortable prac-tice. In particular, I found the section onanalysis useful as a way of conceptualizing,describing, and assembling the many stagesand elements that go into the analysis ofcomplex data sets.

My main problem with the text is theway an approach to research is defined,named, and appropriated by a particulardiscipline, in this case applied nursing re-search. I am not sure this is the best way

to advance good research practice that caninform health care. The process outlined sowell in the text may not be all that differ-ent from what the majority of researchersend up doing when we are in the thickof a qualitative and hence open-ended re-search project, regardless of the school towhich we may claim to belong. The dis-tinctions drawn in the text between “inter-pretive description” and some of the mainsocial theory–based methodologies may beless a product of real disciplinary distinc-tions than one of the distance from whichthese methodologies are described. The verybrief and schematic outlines of ethnogra-phy, grounded theory, and phenomenology(and why just these?) cannot do justice tothe richness and variety of research carriedout under any of these labels. Moreover, Iam not sure everybody would agree withthe descriptions offered. As an ethnogra-pher I did not recognize the research I doin what was described (ethnography as amethod seemed to be confused with anthro-pology as a discipline). Nonetheless, whatI aspire to “do” is indeed “interpretive de-scription,” and this book provides me witha valuable resource in pursuing that goal.

Global Health and Global Aging. MaryRobinson, William Novelli, Clarence Pear-son, and Laurie Norris, eds. San Francisco:Jossey-Bass, 2007; vii + 400 pp.

Peter WhitehouseCase Western Reserve University

Danny GeorgePenn State Medical School

Never in one book have so many influen-tial people and organizations been broughttogether to give us such a global pictureof the effects of aging of our populationson the health of our countries and world.The authors of the volume represent polit-ical and academic leadership from dozensof countries in varying states of economic,social, and demographic development.The diversity of viewpoints and different


national perspectives are rich and appreci-ated, and the editors and authors represent awho’s who of people who have contributedthrough government, NGOs, and universi-ties to our understanding of the challengesthat we face as a result of our growing pop-ulations and the aging of those populations.The reader will discover an extensive re-source for discovery relating to populationdemographics, organizational histories, po-litical treaties, and international reports.

Part 1 details the intricate challengesposed by aging populations around theworld—in both developed and develop-ing countries—and discusses current worldpolicies formulated by the World HealthOrganization (WHO) and United Nations,emerging challenges for the global commu-nity, and strategies for reconciling cross-cultural perceptions of aging. Part 2 featurescase studies on aging issues in 11 differ-ent countries in which researchers discussboth the obstacles and pathways to healthyaging. Part 3 focuses on countries such asChina, India, and Russia, as well as re-gions of Africa and the Eastern Mediter-ranean, that will confront rapid popula-tion aging in the next 20 to 30 years.Part 4 shares information regarding inno-vative programs, partnerships, and researchstrategies for promoting the well-being ofaging persons. Finally, Part 5 provides anepilogue summarizing the main themes fromthe volume and envisioning how the nextseveral decades may unfold.

The lead organization in this impres-sive project is the foundation of the AARP(formerly called the Association for Ad-vancement of Retired People). Yet theinvolvement of AARP—a billion dollar,corporate-like nonprofit organization thatprovides information through various pub-lications to its members (all over 50 yearsold), as well as policy advice to governmentand others, and a wide range of insurance,travel, and health services—is perhaps em-blematic for the entire book. This volume isabout global “bigness”: big ideas, big peo-ple, big organizations, and big problems.But where are the individual human beingsand their local communities? AARP started

small with the vision of Ethel Percy Andrusto serve the needs of retired teachers whowere left without health insurance, yet it hasgrown into a behemoth that influences manybut inspires few.

Similarly, despite being a wonderful re-source, Global Health and Aging leavesmany gaps in our thinking, including re-garding possibilities for action. Aging oc-curs on the ground in individual lives andcommunities. Certain key concepts that willclearly influence the future of the world’selders, and with it the future of our planet,are either missing or not emphasized enoughin this otherwise comprehensive global vi-sion. Although the WHO formulation, men-tioned in the preface, as well as by some ofthe authors, espouses a lifespan perspectiveon aging, a simple search of the index revealsrelatively little about children and intergen-erational issues. Moreover, new ways of for-mulating aging that go beyond successfuland productive aging to positive and spir-itual conceptions are not mentioned. Theethical foundations of global health andaging are not considered in much depth.Perhaps most notably, climate change andother environmental issues are largelyneglected.

Elderly in different parts of the worldare affected by environmental catastro-phes. So far, scholarly analysis of this in-creasingly relevant phenomena has beenlargely limited to Africa and other impov-erished regions where HIV/AIDS, malaria,war, and the absence of clean fresh wa-ter lead to distressingly poor health statis-tics. Yet the impact of environmentaldegradation and wars over energy, wa-ter, and food resources will spread justas quickly as the flow of immigrants intocities and across borders to where oppor-tunities are felt to be greater, and thisvolume would have done well to discussthe global implications of these changes.Moreover, the financial and economic melt-down of 2008 will continue for months, ifnot years, to come and is exposing frail-ties in our economic and political infra-structure. Globalization as a political forcehas its limits, and more thinkers are coming

Book Reviews 509

to see the need for local communities to bemore self-sufficient, a movement that willinevitably alter the consequences of popula-tion aging, both locally and globally.

How will the elder individual be viewedin this new world? How can we integratelife experiences to create a collective wis-dom that will promote species adaptationand survival to adverse social, political, andecological environments? How can we de-velop a more universal ethic of stewardshipat the same time that we respect the diversityof cultural and spiritual traditions? Theseare exigent issues neglected in the book.

A glimpse of answers to these questionscan be found in local communities strug-gling to balance the needs of elders withthe needs of children and the needs of thepresent with the needs of the future. Scienceand medicine will continue to play an im-portant role, but positive aging will be seenthrough a lifespan perspective, and preven-tion interventions will not emerge as muchfrom the drug companies and doctors, butfrom healthy lifestyles and communities. Wemust return to a deeper bioethics as origi-nally formulated by Van Potter and influ-enced by the land ethicists such as AldoLeopold and the deep ecologists such asArne Naess.

What we need now is a book on lo-cal health and local aging to complementGlobal Health and Aging. The kind of bookwe envision would teach us to be more self-sufficient and caring for our neighbors, andhow to create meaningful social spaces inour communities that would be health pro-moting. It would help us develop systemsof public transportation and local food pro-duction. It would make us adopt the precau-tionary principle so that we poured fewertoxic contaminants into our ecosystems. Itwould allow us to feel a reverence and hu-mililty for life that could be informed bymany spiritual traditions. Such would be thebigness of small ideas.

Yes, we need global thinking and globalaction such as action from internationalNGOs and national governments as de-scribed in this book, but we also need lo-cal thinking and local action even more

urgently. Our global thinking about agingshould be based on integrated thinking andholistic valuing and a reinvention of aging asa lifespan process that unfolds in individualswho are part of families, local communities,regions, nations, and, finally, global com-munities.

Ultimately, this book will serve as a re-source for those who seek an authorita-tive, almost encyclopedic perspective of top-down perspectives from powerful peopleand powerful organizations. The world ofaging is changing locally and well as glob-ally, and more ecological, truly intergener-ational and deeper ethical perspectives andpersonal stories are needed to enrich and ex-pand the data and organizational narrativesin this volume.

Return to the House of God: Medical Res-ident Education 1978–2008. Martin Kohnand Carol Donley, eds. Kent, OH: KentState University Press, 2008; xv + 241 pp.

Melvin KonnerEmory University

Return to the House of God is a timely andworthwhile if uneven book. It marks thethirtieth anniversary of The House of God, anovel by Stephen Bergman, M.D., writing asSamuel Shem (1978). Shem’s story was notjust entertaining and insightful; it became aphenomenon in U.S. medicine and especiallyin the culture of medical training, in largepart because of its treatment of that culture’schallenges. I should disclose here that I con-sulted Dr. Bergman for brief psychotherapyin the early 1980s and found him skillfuland compassionate. His book The House ofGod helped me adjust to the clinical yearsof medical school and also helped inspiremy own scholarly inquiry into the system oftraining and its flaws.

On one of The House of God’s previ-ous milestones—the republication markinga million copies sold—the book was gracedwith a preface by John Updike, which isreprinted in the “Return to” collection.What the senior distinguished novelist saidat the time, in 1995, still applies now: “[The


House of God’s] concerns are more timelythan ever, as the American health-care sys-tem approaches crisis condition—ever-moreoverused, overworked, expensive, and besetby bad publicity, as grotesqueries of mis-management and fatal mistreatment outdofiction in the daily newspapers” (p. 105).

The essays in Return to the House of Godsuggest that The House of God made animpression on the thinking of some leadersof medical education, but very little impacton the system. I could say much the sameabout my own work on the topic, whichwas praised by leading physician–educatorsand was even privately said to have playeda small role in the thinking of those whochanged the laws governing residency hoursand supervision. Yet the system is probablyno better now than it was then.

Some chapters in “Return to” try to ex-plain why. Bergman–Shem’s own conclud-ing essay properly decries the unique lack ofa national health care system in the UnitedStates; certainly the inhumanity of our sys-tem as experienced by uninsured patients islargely because of that fact. But when heinvokes U.S. militarism I fail to see the rel-evance; we spend much more, not less, onhealth care than other developed nations do,abandoning scores of millions to their owndevices and not achieving better care forthose we do include. Our sink-or-swim freemarket fundamentalism is at fault, but if ei-ther that or our arms budget explained thebrutalities of medical training they wouldbe radically less common in France, wherethe social welfare state is huge and mili-tarism practically nonexistent; as Marc Zaf-fran’s chapter decisively demonstrates, theyare not.

Better systemic answers are provided inthose by Gerald Weissman and KennethLudmerer, through historical accounts ofU.S. medical training. Residency trainingevolved in an era when the care of hos-pital patients was largely custodial. WhenWilliam Osler famously said, “Live on thewards,” he meant live on the wards so youcan follow the course of diseases, not liveon the wards while mastering scores of pro-cedures, ordering thousands of high-tech

tests, learning one to two orders of mag-nitude more than Osler’s students had toknow, and taking full responsibility for ev-ery mishap in a legal and moral environ-ment of unprecedented hostility. The ten-sion between the need to serve the poor andthe needs of medical training has increased,and the HIV/AIDS epidemic has not helped.This and its associated conditions, especiallydrug-resistant tuberculosis, disproportion-ately affect the poor and therefore add tothe burdens of house officers.

Meanwhile, the takeover of U.S. healthcare by for-profit corporations, focused—by ethical mandate—more on the welfareof their shareholders than that of their pa-tients, has humiliated the medical professionand strongly compromised humane careand training. As Thomas Duffy points out,“There is now a constant effort and pressureto shorten the hospital stays of patients. . . .

The volume of critically ill patients in mod-ern hospitals has greatly increased. . . . Stresshas not been eliminated by the new work-hour restrictions; it has simply been redis-tributed” (p. 194). Ludmerer notes that “acommon denominator of [my] suggestionsfor reforming residency training is that theyare expensive” (p. 32). Thus in the currentenvironment they are off the table.

A number of the other chapters are in thevein of literary criticism of Shem’s novel;they offer anecdotes about how it came tobe or about his (Bergman’s) life, or attempttheir own literary accounts that echo orcounter Shem’s. More of interest, I suspect,to readers of this journal will be such chap-ters as Howard Brody’s revisit of “the lawsof the House of God,” with its emphasis onthe underappreciated value of doing noth-ing; Amy Haddad’s appropriate cry of painagainst Shem’s dehumanizing and belittlingtreatment of nurses as sexual handmaidens;and Jack Coulehan’s thoughtful critique ofthe novel as a cynical and irresponsible workthat perpetuates what it purports to criti-cize.

Although Samuel was a great Hebrewprophet famous for criticizing kings, andshem is the Hebrew word for name, therewas nothing especially Jewish about the

Book Reviews 511

novel, despite “The House of God” being astand-in for a hospital called Beth Israel, or“House of Israel.” Because Bergman’s sec-ond novel, Fine, was about psychoanalysis,it is perhaps not too great a stretch to pointout that Shem also sounds like an Englishword with very harsh connotations. Youcould say that The House of God in partreflected the shame felt by a young traineein what he saw as a shameful system.

An anthropologist might ask not justabout the system, but about the culture thatthoroughly imbues it. Medical training is,among other things, a self-perpetuating ini-tiation rite in which much of the pain isintentional and the most important mes-sages are in the subtext. As Coulehan writes,“Everything we say that is designed to in-still empathy, communication, compassion,trust, fidelity, and an investment in the pa-tient’s best interest constitutes the explicitcurriculum. The hidden curriculum, con-sisting of our day-to-day practices, pushesthese values aside and encourages objec-tivity, detachment, wariness, and distrust”(p. 114).

Or, as I wrote over 20 years ago in myown participant-observer account, the in-tensity of the experience and the nature ofthe models easily sweep away the human-istic and ethical lessons of the preclinicalyears: “The residents are under the great-est pressure they have been or will ever beunder. They are outrageously overworked,sleep-deprived, overburdened with respon-sibility, bewildered by a barrage of ever-changing facts, and oppressed by the med-ical hierarchy, of which they are on thelowest rungs.” And: “Even where the ex-plicit message is, ‘Do as I say, not as I do,’the implicit message is, ‘Do whatever youthink is right, but if you want to survive inthis world you’d better be like me’” (Konner1987:363).

Survival is not a given. As Duffy notes,“Alcoholism, drug addiction, and suicideare occupational hazards. . .the relative risksfor suicide are as high as 3.4 in male physi-cians and 5.7 in female physicians” (p. 192).No one should blame physicians for the cul-tural trap they are in, nor for the ways in

which we as patients are trapped with them.Both The House of God and this collec-tion of retrospective reflections on it demon-strate how difficult it is for members of aculture to change it, even with the best willin the world, and this is where anthropologymay yet be of use.

References Cited

Konner, M.1987 Becoming a Doctor: A Jour-

ney of Initiation in Medical School.New York: Viking Penguin–ElisabethSifton.

Shem, S.1978 The House of God. New York:

Richard Marek.

Women Physicians and the Cultures ofMedicine. Ellen S. More, Elizabeth Fee, andManon Parry, eds. Baltimore: Johns Hop-kins University Press, 2009; xi + 357 pp.

The Changing Face of Medicine: WomenDoctors and the Evolution of Health Care inAmerica. Ann K. Boulis and Jerry A. Jacobs.Ithaca, NY: Cornell University Press, 2008;x + 266 pp.

Joan CassellSaint Louis, Missouri

Each of these two very different booksmakes a valuable contribution to the studyof women in American medicine. In addi-tion, their findings illuminate the wider issueof women’s entry into traditionally mascu-line professions.

The focus of the first volume (based ona symposium held to mark the NationalLibrary of Medicine’s exhibition), WomenPhysicians and the Cultures of Medicine isprimarily historical. The authors are keenlyaware, however, of the relationship of theirmaterial to the current status of women inmedicine.

As with most edited volumes, the qual-ity is uneven. In an attempt to cast a widenet, dealing with a variety of ethnic groups


and medical cultures, and including au-thors at various levels of professional matu-rity, some contributions—let them remainnameless—consist of little more than collec-tions of data, of interest primarily to schol-ars specializing in that mini-area of medicalhistory. The motive is admirable, but theresults are, on occasion, somewhat dull. Incontrast, most of the essays are absorbing,blending scholarship with intellectual pas-sion for their subject.

And, of course, the struggle of Americanwomen to enter medicine is fascinating, be-ginning with Elizabeth Blackwell’s gradua-tion from Geneva Medical College in up-state New York, in 1849—an experimentso perilous that the college decided not torepeat it, closing their doors to women. Thesection on female pioneers and their chal-lenges to received wisdom about women’sbodies and abilities is absorbing.

Carla Bittel describes how Mary Put-nam Jacobi wielded her scientific exper-tise to challenge conventional beliefs aboutwomen’s fragile bodies, contending thatmenstruation, rather than being a sign ofweakness, difference, and incapacity, wasa sign of vitality. Jacobi utilized scienceas a political weapon to justify educatingwomen, challenging the notion that men-tal and physical activity was dangerous orjeopardizing to women’s psychic health andreproductive ability.

Arlene Tuchman examines Marie Za-krzewsa’s attempt, in her work and life, tocounter the notion that women’s bodies ren-dered them physically and intellectually in-capable of practicing medicine. Convincedthat a sharp differentiation between maleand female bodies would confine women toa subordinate personal and medical status,Zakrzewska minimized the biological dif-ferences between the sexes and refused toaccept the argument that women were in-clined by their nature to practice a kinderand gentler medicine. Her views altered nearthe end of her life when, unmarried, child-less, and no longer connected to the nur-turing community of the hospital she hadestablished, Zakrzewska accepted conven-tions she had vigorously opposed and con-

cluded that motherhood was women’s “nat-ural mission.”

Regina Morantz-Sanchez discusses thesensational 1892 Mary Dixon Jones libeltrial. Following a series of lurid articles inthe Brooklyn Eagle depicting the gynecolog-ical surgeon as a knife-happy harpy, the re-sulting publicity generated two manslaugh-ter and eight malpractice suits, which DixonJones won. But when she then sued theBrooklyn Eagle for libel, a male jury foundthe journal innocent. Morantz-Sanchez ar-gues that the trial did more than pun-ish an unruly woman for arrogance, self-promotion, and refusal to defer to her malecolleagues: Testimony of female patients,and the unprecedented number of womenviewing the trial, illustrates how Americanwomen at the turn of the 20th century werebecoming increasingly active as consumersof new health treatments. Evidence from thetrial illustrates how the emergence of sur-gical gynecology challenged dominant dis-courses about the moral necessity of femaleself-sacrifice and suffering and presented adifferent image of women for public con-sumption.

In a section on challenges to the culture ofprofessionalism, Robert Nye describes the“honor culture” of 19th-century medicine,with latent violence simmering below thesurface of fraternal sociability. A physicianwas supposed to be a “gentleman”—a sta-tus no woman could attain. Women had,and still have, the wrong bodies, the wrongmovements, the wrong habitus. Although awoman physician may behave and think ofherself as “one of the boys,” sooner or latershe’s likely to discover, as did neurosurgeonFrances K. Conley, that the “boys” still dis-value her as a “girl.”

Naomi Rogers describes the ways inwhich feminists in the 1970s and 1980sfought the culture of exclusion in medi-cal education. A vicious species of humor,which marginalized, harassed, and excludedwomen, was one of the weapons deployedby the culture of “the boys in white.”U.S. medical culture in the mid-20th cen-tury was hostile to women, Jews, Catholics,and African Americans. White, primarily

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Protestant, homogeneity was taken forgranted, not only by physicians but alsoby (not necessarily Protestant or male) so-ciologists depicting medical education (seeBecker et al. 1961) Rogers outlines the as-sumptions challenged by a new activist gen-eration of female medical students who re-fused to be classified as “gentlemen” or evenas “ladies.”

A concluding chapter deals directly withthe opportunities and obstacles for womenphysicians in the 21st century. With in-telligence, sensitivity, and a wide familiar-ity with the relevant literature, the editorstouch on topics such as “balancing personallife with a career in medicine,” “the relation-ship between physician health and patienthealth,” and the pressing issue of whetherthe entry of more women has managed totransform U.S. medicine as so many femi-nists hoped.

Various chapters in this volume wouldmake absorbing reading for undergraduatecourses in medical anthropology as well asgender and professionalism. One or twomight even provoke reflection and discus-sion in premed classes. Some of the more so-phisticated analyses, including the editors’introduction and conclusion, would also beuseful in graduate anthropology, sociology,and gender studies courses.

In contrast, The Changing Face ofMedicine: Women Doctors and the Evolu-tion of Health Care in America is, at leastat first, rather heavy going. As a staunchlyqualitative researcher, I found the first fewchapters overly dense. The more I read,however, the more I began to appreciatethe authors’ rigor, intelligence, and scrupu-lous analysis, not to mention the staggeringamount of literature with which they displayan impressive familiarity.

The authors offer a social scientific viewof what occurred and is occurring, show-ing how structural factors outside the con-trol of individuals affect the course of U.S.medicine. They have found ways of present-ing and illuminating quantitative data, ingraceful prose and immediately comprehen-sible graphs, that could—and should—actas a model to students and other researchers.

It is not surprising that the acknowl-edgments discuss the “long gestation” ofthis project. The book is a remarkableachievement, dealing with pressing issuesraised by the gradual feminization of U.S.medicine.

“The Gendered Map of ContemporaryMedicine” describes the current state of gen-der inequality and shows how this inequal-ity has changed over time. The authors ana-lyze inequality in specialty fields, practiceownership, patient profiles, research andfaculty positions, and leadership positions,presenting statistics and acute analyses ofwhat these show.

“Gender Sorting and Tracking” ana-lyzes the allocation of men and womenacross specialties, outlining the persistenceof the segregation by specialty discussedin the previous chapter. Women studentsand residents are encouraged to enter fieldssuch as pediatrics and family practice withlower incomes and, frequently, less pres-tige than the specialties advisors considersuitable for men. Subtle discrimination,gender stereotypes, and outright harass-ment combine to continue this specialtysegregation.

Three chapters that I found particularlyengrossing deal with the questions raised inthe conclusion to Women Physicians andthe Cultures of Medicine: “Work, Fam-ily, Marriage, and Generational Change,”“Women Physicians Caring for Patients,”and “Medicine as a Family-Friendly Profes-sion?” (note the question mark). Among thecritical issues covered with insight, intelli-gence, and abundant statistical and quali-tative data are: parenting and work hours;the impact of work on family life; physi-cians’ marriages, including those betweenphysicians; gender and the treatment of pa-tients, with a discussion of whether morewomen make for a more empathetic pro-fession; whether the medical workweek iskinder and gentler or crazier than ever, andwhether today’s physicians are workaholicsor overworked; and an exploration of theculture of unfettered professional commit-ment, with an analysis of the cultural, orga-nizational, financial, and personal obstacles


to part-time work in medicine. The authorsdiscuss the 80-hour-per-week rule for res-idents, explaining how it developed; andthen outline the costs of inflexibility in thelives of individual male and female physi-cians, focusing on how this inflexibility af-fects women, mothers in particular. Eachof these chapters would make thought-provoking reading for undergraduate andgraduate students of medical anthropologyand sociology, gender studies, and profes-sionalism in U.S. life.

The conclusion makes limited predictionsabout future trends. It focuses on four ques-tions: whether the feminization of medicinewill continue, whether medicine will be-come more caring and patient-centered,whether women will lead medicine in bravenew directions, and whether women willbolster issues regarding women’s health.The authors focus on the role of social pres-sures and independent structural change inimpeding progress, rendering their predic-tions cautiously optimistic. They predictthat as the number of women physiciansgradually increases, incremental change willoccur.

The 10-page appendix, outlining andevaluating the data used for the analysis pre-sented in each chapter, is worth the priceof the book. It should be required readingin courses on social science methodology.Not only does it contain a scrupulous dis-cussion of the strengths and weaknesses ofvarious sources of data, it indicates just howthe authors employed, supplemented, andtested each source. This plus the 24-pagebibliography provide an invaluable resourcefor students and researchers. Although I be-gan reading The Changing Face of Medicinewith reservations, I’ll return to it many timesas a reference source.

Reference Cited

Becker, Howard S., Blanche Geer, EverettC. Hughes, and Anselm L. Strauss

1961 Boys in White: Student Culture inMedical School. Chicago: Universityof Chicago Press.

Medicine’s Moving Pictures: Medicine,Health, and Bodies in American Film andTelevision. L. J. Reagan, N. Tomes, and P.A. Treichler, eds. Rochester, NY: Universityof Rochester Press, 2007; vi + 343 pp.

Elizabeth CartwrightIdaho State University

The sheer power and drama of bodily dis-tress and disease has long provided the rawmaterial for creating compelling visual me-dia. Whether it is through the ongoing tele-vision dramas, soap operas, and dramaticfilms of the era or through educational pro-ductions, nearly as soon as the technologyof film was invented we began projectingourselves and our concerns onto big (andsmall) screens. The shape and moral con-tent of these filmic narratives are the sub-jects of this edited volume. These authorsargue that what we know about our bodiesand our selves is as much due to what we’veseen on television and at the movies as it is aresult of the efforts of our biology teachersand anxious parents.

This volume explores the effects of vi-sual media on individuals within cultures.The effects are rarely direct, and they aredifficult to describe and to quantify. Eachchapter critically focuses on a particular as-pect of how film and television have por-trayed our bodies in sickness and in health.Overall, this volume presents us with well-researched examples of how a century ofmoving pictures has formed a thick layerof highly constructed and culturally medi-ated understanding in each of us. It is theall-pervasive nature of this information thatis truly overwhelming—it is everywhere weturn, and, thus, it is nowhere.

How are we to grasp the transfer of filmicinformation about what it means to be agendered body, a less-than-whole body, adamaged or diseased body, when the im-ages that most powerfully influence us areseductively embedded in drama, in “oursoaps” and in what is presented as “scien-tific” health information? The first step isseparating out the images from their filmiccontexts, and that is surely the step that was

Book Reviews 515

taken by this volume. By carefully dissectingthe cultural context of the era and in fol-lowing the creation and use of the “thing”(i.e., the film), we are given a clearer un-derstanding of how and why the films weremade, distributed, and accepted (or not) inthe ways in which they were.

This volume deals with educational filmssuch as those created to teach women todo self-exams for breast cancer (Reagan),and Hollywood films depicting celebritieswith the diseases that they became emblem-atic for, such as the life story of the base-ball player Lou Gehrig, who suffered fromamyotrophic lateral sclerosis and whosename became synonymous with that dis-ease (Tomes). A section of the book decon-structs some of the films that made our med-ical heroes from the past. One example isindomitable Australian nurse Sister Kenny,who espoused a radical departure from stan-dard AMA treatment protocols for poliovictims, and who is revealed in this volumeto have been not only a great clinician butalso a media-savvy woman who was directlyinvolved in the creation of her own screenimage (Rogers).

The chapters in this volume provide closereadings of such topics as the script de-velopment that occurred on General Hos-pital when one of the handsome youngleading men was scripted to come downwith HIV/AIDS (Treichler). This chapter de-scribes how editorial choices were madeabout how to present the topic of AIDSto prime-time viewers of this popular soapopera. Although the effects of showing acharacter dying from HIV/AIDS on GeneralHospital are not quantified (indeed, theymay not be quantifiable), the impact of day-time television on our cultural subconsciousshould not be underestimated.

Another topic that this volume explores ishow the formulas for television medical se-ries and dramas have changed over time andhow those changes reflect television audi-ences’ changing stereotypes of medical per-sonnel. The authors trace how admirationand faith in doctors who were the heroesof 1960s television shows gave way to con-temporary medical TV that emplots the per-

sonal foibles and sexual affairs of medicalprofessionals trapped in the overburdenedand, at times, absurd world of hospitals andclinics of the 21st century (Turow and Gans-Boriskin).

As a teaching tool, I would be temptedto use this book as the basis for a classon the subject of medical media in contem-porary culture. In addition to what has al-ready been discussed here, this edited vol-ume provides a clear roadmap through vi-sual terrain that deals in a thoughtful andcomplex manner with the anthropologicalsubject matters of race (Northington Gam-ble), medical ethics (Lederer), new genetictechnologies (Hartouni), and feminist cul-tural critiques of the visual representationsof individuals with disabilities (Cartwright,no relation). In the classroom setting, thevisual media discussed in the various chap-ters could be shown either as strategic clipsor in its entirety, depending on availability.Increasingly, in works such as this editedvolume, I want to see what the authors aretalking about, and I would like to encour-age the editors to create a multimedia for-mat where they would present clips of theirsubject matter within the context of theirwritten academic works. An accompanyingDVD or a companion website would go along way in engaging today’s students withthis subject matter. As we learn to thinkmore complexly and (necessarily) more vi-sually, it behooves our discipline to embracea more multimedia environment.

With respect to advancing medical an-thropology’s theoretical sophistication, asthe editors of this volume state in the intro-duction, the studies are conceptualized as afirst step in an exploration of how we pro-duce and consume fictional and nonfictionalfilmic images of diseases and of the enact-ment of healing. The next step is more diffi-cult. The editors and authors of Medicine’sMoving Pictures: Medicine, Health, andBodies in American Film and Televisionhave provided us with well-documented,historical descriptions. Now the questionbecomes how to carry out contemporaryresearch projects that analyze the ongo-ing production and consumption of medical


visual media in a manner that is increas-ingly systematic and focused with respect tothe theoretical questions that we ask andthe methods that we use to answer them.

Exit: The Right to Die. Released October25, 2006. First Run–Icarus Film, Brooklyn,New York; 75 min.

Donald JoralemonSmith College

There are five organizations in Switzerlandthat provide assistance to people in end-ing their lives when suffering becomes in-sufferable. For the French-speaking sectorthat organization is “Exit” (also knownas Exit ADMD [Association pour le Droitde Mourir dans la Dignite]). Membership,restricted to Swiss nationals and residentforeigners, entitles one to request that an“escort” provide ten grams of pentobarbi-tal mixed with fruit juice to permit “self-deliverance,” a “journey” into the light.Filmmaker Fernand Melgar takes us behindthe scenes to see how this work is done andwhat it means to those who volunteer toassist in someone’s death.

This slow-paced film follows Exit per-sonnel and Exit’s leader, Dr. Jerome Sobel,through home visits, office work answer-ing phone messages, a membership meeting,and an international conference on deathwith dignity. Two volunteers stroll thougha misty meadowland reflecting on recentcases. A gathering of “escorts” to assign newclients reveals the toll the work takes on thevolunteers. A culminating assisted death ata sufferer’s bedside shows how Exit person-nel strive to assure their client knows whatis about to happen and is absolutely certainabout the decision. Administrative routines

are juxtaposed with touching interactionsbetween terminally ill patients and Exit vol-unteers, who commit to a personal relation-ship with each client through multiple visits.There is a disquieting voyeuristic quality tothe viewing experience.

I showed the film to my class on “Dyingand Death” and asked for their responses.They noted that there is no narration be-yond the recorded conversation of Exit per-sonnel and members, phone callers to theorganization’s office, and persons being as-sisted. The use of the above-mentioned eu-phemisms did not escape their notice, nordid the fact that the camera retreats at thelast minute for the one client whose death isdocumented. My students judged the film tobe a valuable look at the practical function-ing of the organization, especially related tothe rules that establish who may and maynot be helped, but they also judged it onesided. Several wished the views of the widersociety had been included. They agreed thatthe compassion of the volunteers is a pow-erful element in this positive representationof assisted death.

The continuing debate about physician-assisted suicide in the United States makesthis documentary a useful catalyst for classdiscussion. It opens the door to a consider-ation of “rights-based ethics” in medicine,cross-cultural variations in end-of-life de-liberations, and distinctions between “ac-tive” and “passive” euthanasia. It mightusefully be paired with videos, widely avail-able on the Internet, of opponents to assistedsuicide. At 75 minutes, the film is a littlelong for class use; some additional editingof repetitive scenes and prolonged camerashots could have increased the film’s peda-gogical utility. It is, nevertheless, a signifi-cant contribution to the visual resources indeath studies.

Documents

Interpretive Description by Sally Thorne