The Changing Medical Profession: An International Perspective by Frederic W. Hafferty;John B. McKinlayReview by: Michael M. RachlisCanadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 86, No. 3(MAY / JUNE 1995), pp. 212-213Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41991288 .

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BOOK REVIEWS

RECENSION

Women, Work, and Coping: A Multidisciplinary Approach to Workplace Stress

B.C. Long, S.E. Kahn (Eds.). Montreal , QC: McGill-Queen s University Press , 1 993; $49.95 cloth , $17.95 paper, xviii + 334 pp.

This book had its genesis in a research workshop co-sponsored by the Academic Association at the University of British Columbia. Twenty participants were invit- ed to address the important subject of how women cope with workplace stress, and to continue their discussion by contributing to this volume. The book's 14 chapters are divided into five sections: 1) an overview of women and work; 2) employed women in context; 3) coping resources: stress modera- tors; 4) appraisals and coping strategies; and 5) women's ways of coping: research and theoretical implications.

The challenge for researchers is formida- ble, given that the subject is complex and ever-changing. The importance of the sub- ject material is undeniable. Women are entering the paid workforce in ever greater numbers. They experience multiple roles, sex role stereotyping and competitive orga- nizational cultures, to name only three of the many stressors in their lives. Despite this, some studies show that women in multiple roles demonstrate fewer negative health consequences than do those with fewer responsibilities.

This book will be of interest to acade- mics, students and researchers studying work and the role of women in the work- force. While interesting in a theoretical way for managers, health practitioners and policy-makers, it does not provide the con- crete information necessary for making modifications to workplace policies and practices. Some studies of interventions such as flexible hours of work, job sharing, or workplace daycare would have been wel-

. come.

Verna Wilson, MHA, BSc(N) Assistant Director, Adult Health Directorate Ottawa-Carleton Health Department Ottawa, Ontario

Prevention of Respiratory Diseases (Lung Biology in

Health and Disease) A. Hirsch, M. Goldberg, J-P Martin, R. Masee. New York, NY: Marcel Dekker, Inc., 1993 ; $185.00 US, 744 pp.

This book is published as a volume in the series "Lung Biology in Health and Disease". The text covers a broad range of topics but confines itself primarily to the prevention of respiratory diseases related to environmental exposure, and excludes the prevention of respiratory disease by immu- nization or chemoprophylaxis.

The book is divided into four sections: occupational diseases; environmental sources of respiratory diseases; biological markers; and tobacco-related respiratory diseases. The section on tobacco and respi- ratory diseases is particularly strong; it con- tains a number of excellent chapters on smoking cessation, culminating in a chapter on the evolution of a comprehensive anti- tobacco policy. Reading this section and reflecting on the disastrous decision by the federal government and many of the provinces to reduce taxes on tobacco, is a sobering experience.

Other sections give excellent overviews on occupational lung disease and indoor air quality (including a detailed assessment of the sick building syndrome). Respiratory tract malignancies and their association with smoking are covered in some detail. This textbook will appeal to a broad range of readers, from public health specialists to clinicians, and to those with an interest in health policy, especially as it relates to envi- ronmental exposure and cigarette smoking. The material presented is highly relevant to Canada.

This book will likely prove too expensive for many individuals, but it would be a use- ful addition to reference libraries, especially those of non-governmental organizations interested in lung health.

Mark FitzGerald, MB Assistant Professor, Department of Medicine University of British Columbia

The Changing Medical

Profession: An International

Perspective

Frederic W. Hajferty, John B. McKinlay (Eds.). Don Mills, ON: Oxford University Press, 1993 ; $66.50, xii + 261 pp.

This book should be on the reading list of everyone interested in health policy, especially the sociology of health. Although it is a multi-authored monograph, the dif- ferent chapters hold together remarkably well. The editors have deftly bracketed 1 1 national case studies of the medical profes- sion with four introductory chapters on theoretical issues and three concluding chapters on cross-national analysis. The authors are well-known academics from ten countries. They are mainly from the field of sociology, but law, medicine and policy analysis are also represented.

The book features a continuation of a long academic debate between American sociolo- gist Eliot Friedson and his protagonists, including co-editor John McKinlay. The dis- cussion concerns whether the medical profes- sion is still "dominant" (to use Friedson's term) or whether it is in decline through "deprofessionalization" or "proletarianiza- tion". In their concluding chapter, the edi- tors suggest that at any given point in time, the profession will display ascendancy in some areas, decline in others, and mainte- nance activities in most. In many countries, it appears that the medical profession is los- ing some of its influence over the organiza- tion of health care services while maintaining its autonomy over medical practice and extending its reach into society through the increasing "medicalization" of life processes (infertility, menopause, etc.).

The Canadian chapter is written by David Coburn, a professor of behavioural science at the University of Toronto. He concludes that in general, the Canadian medical profession is losing influence. Doctors are less able to control the organization of health care deliv- ery and are gradually losing control over the governance of the profession. For example, Ontario licencing legislation for physicians now includes a much wider public scrutiny of all decisions. However, Coburn, like other authors, concludes that it is premature to dis- count medicine's political power.

In conclusion, this book should be inter- esting reading for doctors, sociologists, poli-

212 REVUE CANADIENNE DE SANTÉ PUBLIQUE VOLUME 86, NO. 3

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BOOK REVIEWS

cy analysts and others concerned about the evolving role of the medical profession.

Michael M. Rachlis, MD, MSc Epidemiology , Program Evaluation , Policy Analysis Toronto , Ontario

Confronting Drug Policy: Illicit Drugs in a Free Society R. Bay er y G. M. Oppenheimer (Eds.). New York , NY: Cambridge University Press , 1993; $59.95 cloth , $19.95 paper, vii + 369 pp.

For decades, drug policy in most parts of the world has been marked by punitive approaches against drug users. This book joins the growing chorus of complaints against such policies. It covers the financial, social and health costs of current policies in a thoughtful manner. The contributors are established scientists and jurists prominent in the drug policy field. However, there is no chapter by an apologist for the current drug laws, nor even a half-hearted defence of them.

The audience for this book will be drug policy specialists and other professionals interested in drug policy. It might be of interest for some more liberal civil servants and parliamentarians who propose, draft and pass drug laws.

As with most recent books of drug policy, this one deals mainly with laws in the U.S.A. There is one chapter on "foreign models" for U.S. drug policy mostly dealing with heroin prescribing policy in Britain and cannabis policies in the Netherlands. Canadian drug policies are mentioned a few times, but Canada did not get into the index.

This book makes strong arguments for a reanalysis of drug policies in the U.S. and elsewhere. However, it will not convince most readers that drug use could not expand if legal controls were diminished. Despite its dependence on American drug experiences, this book is recommended as it discusses important policy issues. However, its solutions will require more discussion before being accepted as the basis of new drug policies.

Reginald G. Smart Addiction Research Foundation Toronto, Ontario

Why Are Some People Healthy and Others Not? The

Determinants of Health of

Populations

Evans RG, Barer ML, Marmor TR (Eds.). New York: Aldine de Gruyter, 1994; 378 pp.

The editors and authors of this book are members of the Program in Population Health of the Canadian Institute for Advanced Research. The stated purpose of the book is to describe "anomalous findings" about the determinants of health to support a paradigm shift in the scholarship of health. The editors also indicate their hope that the book will demonstrate the importance of fac- tors other than medical care and will reduce the confusion arising from "the peddling of simple conceptualizations of complex phe- nomena." They include in the latter improved diet, more exercise, less stress, bet- ter medical care and genetic engineering.

Many of the concepts presented in this book are not new to anyone trained or experienced in public health. The social, environmental, biologic and behavioural determinants of health have been recog- nized for many years. The health determi- nants model presented in this book and elsewhere is an expansion of concepts pro- nounced in "A New Perspective on the Health of Canadians" published over 20 years ago. Perhaps the major improvement of the new model is the removal of the "blame the victim" sentiment of the New Perspective model.

The "anomalous findings" presented in the book are open to various interpretations. For example, much is made of the observation that there was a gradient of increasing coro- nary heart death rates for males aged 40 to 64 in the Whitehall cohort study as occupational categories decreased from senior administra- tive grades to clerical and manual grades. The authors note that this gradient was only par- tially explainable in terms of smoking, blood pressure and cholesterol and hold that "there is something that powerfully influences health and that is correlated with hierarchy per se." They propose that a general causal process associated with hierarchy expresses itself through various diseases and that the particu- lar diseases simply represent alternative path- ways; the essential factor is something else.

This sounds a bit like "the peddling of simple conceptualizations of complex phenomena" that the authors attribute to others. Although this particular anomalous finding is interest- ing, the authors do not cite other studies showing, for example, that smoking alone explains 40-60% of fatal and non-fatal coro- nary heart disease events among middle-aged persons of either sex. Most of the decline in coronary heart death rates in North Karelia and Kuopio provinces in Finland among per- sons aged 30-59 during the period 1972-92 was explained by changes in the three main risk factors. Also, the authors do not discuss the fact that measurement errors dictate that we will usually be unable to explain all the variance in the relationship between risk of a disease and its multiple risk factors. Moreover, currently unknown risk factors may explain some of the variance not explained by the known factors; a possible example is the B-vitamin folic acid which may be important in coronary heart disease and for which defi- ciency should be more prevalent among low income groups.

Stress is undoubtedly a major factor in human health either as a direct or indirect cause of illness and suffering. However, it is risky to attribute to stress or some elusive factor those health phenomena not easily explained by our current knowledge. Peptic ulcers were, until recently, considered to be classical stress-induced health effects. There is growing evidence that a high proportion of these ulcers are caused by the microor- ganism Helicobacter pylori and good evi- dence that healing and prevention of recur- rence of peptic ulcers is achievable through antibiotic treatment.

Notwithstanding the above, I believe that this book offers important information and ideas for health professionals. First, the cur- rent concern about government debts and rising health care costs is unavoidable and the book reminds us of the importance of the broad determinants of health. Second, the anomalies described in the book beg further research and debate. Finally, the plea in the final chapter by Michael Wolfson for improved data on health status and health costs including individual histo- ries is well placed.

Don Wigle Laboratory Centre for Disease Control Health Canada

MAY - JUNE 1995 CANADIAN JOURNAL OF PUBLIC HEALTH 213

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