by Gita Sen, Asha George & Piroska Ostlin (editors)
MIT Press, 2002
Review by Mark Welch, Ph.D. on Oct 18th 2002
This is a very rational
book, and it that lies both its greatest strength and its greatest weakness.
The authors, all of whom are eminent and well qualified in the field, set out
to persuade that unless public health changes direction, it cannot effectively
address the needs of those who are most marginalized, many of whom are women.
It does so by producing cogent and impressive evidence from the developed and
developing worlds to show that equity in health status and the provision of
care is far from the norm, and further, that a gender and health analysis (is)
cross-cut by concern for other markers of social inequity, such as class and
It may be said that overall
it is more successful in its first objective than the second. This is not to
suggest that the integration of an essentially feminist analysis with a broader
social critique is unworthy or unworkable, but rather to point out the
predominance of concern within the book.
The text is in 13 chapters
divided into two parts. The first section is concerned with key health areas
and covers topics such as work, reproductive health, mental health, violence
and the public policy debate. The consideration of the burden of disease,
disability and ill-health and mental health is particularly relevant. It lays
out the argument in a stark and self-justifying manner, and demonstrates convincingly
that the gender determinants are indeed of major importance. It advocates a
mental health rather than a mental illness policy, and methods to
counteract the cumulative psychological adversity of womens social
positions. It also, to its credit, links physical and mental health concerns
and raises the issue of male and female mental health risks in reproduction. It
is not so hard to develop the line of argument to advocate mental health
literacy and a broad approach to health promotion, capacity building and strong
proactive policies. However, there are also largely unsubstantiated claims,
such as the assertion that high rates of depression in women and alcohol
dependence in men, both of which seem undeniable, strongly indicate a large
unmet need for improved access to low-cost, or preferably no-cost,
gender-sensitive counseling services. Not only is the concept of unmet need
notoriously difficult to quantify, but the logical deduction is unproven and
the value-bias in the statement unacknowledged. Astbury, the author of this
chapter, may well be right, that such counseling services would be a good thing
and a positive social policy, but she cannot assert proof such as she claims.
This is an issue that bedevils the book as a whole.
The second part of the book
is built around the theme of research and policy, and it is here that the
difficulty with an unexamined rationalism emerges even more clearly. While the
policies advocated are in general supported by the WHO and other international
bodies, and use, quite properly in my view, a stance on human rights based on
the United Nations Declaration, the authors do not critically evaluate them in
the face of an increasingly vocal anti-Western and anti-rationalist stance. As
a result, they can seem to be prone to the same sort of cultural bias and
blindness that they critique. Issues as important as this cannot be left simply
as polemical statements. They must engage in rigorous and forceful debate. It
seems that any argument is always more convincing and less strident if it can
be seen to understand and counteract the opposing viewpoint. Had the authors
done this more thoroughly the book as a whole would have even greater merit
than it does.
As it stands, the book is an
excellent addition to the literature. It attempts to bring together a number of
different strands of analysis and incorporate them in to a global perspective.
It sheds important light on a neglected subject, and if for no other reason
than this should be widely read. However, it is much better on the what of the analysis than the how of the solution. Perhaps this is the
© 2002 Mark Welch
Mark Welch is currently a Senior Lecturer and Postgraduate Coordinator in The School of
Nursing at the University of Canberra, Australia. His PhD investigated the
representation of madness in popular film, and his other research interests
include the mental health of refugees and victims of torture, and the history
of psychiatric epistemology.