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Health Policy & Advocacy

by Gita Sen, Asha George & Piroska Ostlin (editors)
MIT Press, 2002
Review by Mark Welch, Ph.D. on Oct 18th 2002

Engendering International Health

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 race”.

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 women’s 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 next step.

 

© 2002 Mark Welch

 

Dr 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.