This book resulted from the National Council for International Health’s
conference on Women’s Health: The Action Agenda held in 1991 in Arlington,
US. But unlike most conference proceedings, it is more than a sequence of
edited papers. Instead, each chapter gives an overview of all the papers
presented on a topic. They include women’s health and poverty, nutrition
through the life cycle, infection, family planning, abortion, women’s mortality,
violence against women, women’s mental health, access to care, quality of
women’s health care and methods of eliciting women’s views. The result is
an extraordinarily comprehensive and up-to-date review of evidence about,
and issues surrounding, women’s health.

Covering a range of contemporary societies mainly in developing countries,
The Health of Women only partly lives up to its subtitle, ‘A global perspective’.
But it is particularly interesting for those more familiar with the literature
on women’s health, and gender differences in health, in industrialised
countries. We are used, for example, to the idea that women have lower mortality
rates than men. So it is striking when examples are given of the opposite,
as in the observation that in Bangladesh female mortality exceeds male
mortality by 59 per cent to 77 per cent between the ages of one and four
years. In Northern Europe only one in 9850 women will die of complications
of pregnancy or delivery: the comparable figure for Africa is one in every
21 women.

The book contains a host of similar observations about women’s health
and its determinants: that voluntary surgical sterilisation is illegal in
Chile, Iran, Peru, Saudi Arabia and Burma; that in Korea the numbers of
girls and boys being immunised against measles were almost equal when immunisation
was provided free, but that when a small fee was charged, the proportion
of girls going unimmunised fell disproportionately; and that it has been
estimated that one in five women of reproductive age in Romania suffers
from infertility caused primarily by unsafe abortions.

As the introduction states, the Health of Women is written with a sense
‘of rage at the inequities and neglect of the past’. The impact of this
style is variable. One of the most effective passages occurs in the introduction
to the first chapter: ‘Two out of three women around the world presently
suffer from the most debilitating disease known to humanity. Common symptoms
of this fast-spreading ailment include chronic anaemia, malnutrition,
and severe fatigue. Sufferers exhibit an increased susceptibility to infections
of the respiratory tract. And premature death is a frequent outcome. In
the absence of direct intervention, the disease is often communicated from
mother to child, with markedly higher transmission rates among females than
³¾²¹±ô±ð²õ.’

No, this disease is not HIV; it is poverty.

While many of the analyses and policy recommendations engage with important
contemporary debates among development workers and agencies, some are equally
relevant to developed countries. For example, the book includes a discussion
of the neglect of women in studies of cardiovascular disease in the developed
world. And it offers an analysis which suggests that the only way to cut
maternal mortality may be the provision of good-quality emergency medical
care, unlike infant and child mortality, which are responsive to improvements
in socioeconomic conditions.

Although I feel unable to judge the validity of some arguments relating
specifically to developing countries, and would quibble with some relating
to developed countries, overall I recommend this book as a comprehensive
and thought-provoking account not only of women’s health, but also of women’s
lives, in today’s world.

Sally Macintyre is director of the Medical Research Council’s Medical
Sociology Unit at the University of Glasgow.

LYNN PAYER is a medical journalist who, having had her own thoughts
about health and medicine provoked by spells outside her native US, has
written a thought-provoking book about how medical practice is embedded
in culture. Having started out believing that European deviations from American
medical norm were the result of backwardness, she came to see how cultural
prejudice influences American ways of perceiving and managing health and
sickness as it does those of any other country. Although she intended to
write about a larger number of countries, she eventually confined herself
to France, West Germany, Britain and the US.

The differences between these four countries in their notions of health
are fascinating. Particularly interesting are the ‘wastepaper-basket’ categories
of diagnosis she identifies: in France, there is spasmophilia and crise
de foie and Herzinsuffizienz and vasovegetative dystonia in West Germany,
and viruses in the US.

Although the absence of hard comparative data, often frustrates her,
Payer is sometimes able to make extremely illuminating quantative comparisons
between countries. For example, did you know that there are 120 000 different
drugs on the market in West Germany, compared with 1180 in Iceland? That
rates of coronary bypass surgery are up to 28 times as high in the US as
in some European countries? That the frequency of consultations for low
blood pressure was 0 per million in England and 163 per million in West
Germany? Or, indeed, that the low blood pressure treated with 85 drugs as
well as hydrotherapy in West Germany would entitle its ‘sufferer’ to lower
rates for life insurance in the US? Anecdotes shed other light on cultural
differences. I especially liked the story that young journalists in the
US are taught never to write in an obituary that someone died of ‘natural’
causes, apparently because no one ever considers death to be natural.

Though an enjoyable read, the book is poor on analysis, as the author
admits. She tends to take at face value the explanatory theories of her
sources in the various countries, and thus concludes that Descartes produced
French medical thinking, romanticism German, and the empiricists Locke,
Berkeley and Hume were responsible for British medical attitudes as the
frontier experience was for American. Such conclusions beg the question
of the relationship between philosophers and the cultures from which they
come, and of the relationship between medical, scientific and lay thinking
about health and illness.

I was initally irritated by the lack of any reference to the material
being cited; it was only when I had finished reading the book that I discovered
that there were references and footnotes, but they were all bunched together
at the end and completely unsignposted in the text.

The book bears comparison with a BBC Horizon programme; interesting
and enjoyable, with contributions from a range of knowledgeable key informants,
but ultimately disappointing to those who know about the subjects in any
depth. As with Horizon programmes, however, the book’s value may well lie
in stimulating people’s awareness of the topic and encouraging them to pursue
it further.

Sally Macintyre is director of the Medical Research Council’s Medical
Sociology Unit, Glasgow.