1586 Book Reviews

I believe this volume could be reduced in size significantly by omitting such general discussions of health policy and program management covered in chapters 1, 2, 7 and 8. Actually all sections covering ‘integrated health services’ ‘decentralization’, ‘management system’, etc. could have been more coherent and probably more suitable in a differ- ent book. They appear to be not only unnecessary in this volume, but also an after-thought. The volume could have been more focused on LQAS, its power, relevance, robust- ness and superiority without these extraneous discussions.

Otherwise it is a good teaching and practical volume. At $10.95, Assessing Child Survival Programs . . . might not be affordable in most African countries where commu- nity/public health training and practice is becoming increas- ingly popular.

USAID /Tanzania P.O. Box 9130 Dar es Salaam, Tanzania

F. M. MBURU

Who Plays? Who Pays? Who Cares?: A Case Study in Applied Sociology, Political Economy, And the Community Mental Health Centers Movement, by SYLVIA KENIG. Bay- wood Publishing Company, Amityville, NY, 1992. 221 pp., S28.95 (hardback), $21.75 (paperback).

If the ambiguous title and lengthy subtitle of this book don’t immediately make clear its purpose and subject, don’t expect things to improve instantly once you begin to read it. As the author states in the first sentence of her introduc- tion “This is a book of many parts”. Like a home appliance that arrives in a cardboard box labeled “some assembly required”, the many parts of the book don’t always seem to fit together smoothly, it doesn’t always follow the “assembly diagram” provided in its introduction and it may leave the reader wondering whether s/he has put it together properly. Despite these caveats, I believe that Kenig has produced a book that is worth the investment of time and effort necessary to assemble all of the pieces.

This book is the first in a new series entitled “Critical Approaches in the Health Social Sciences” forthcoming from Baywood Publishing. Essentially it is both a social history of the Community Mental Health Center (CMHC) movement in the United States, written from the critical perspective of class based conflict theory, and an applied sociological analysis of how the changing meanings attached to the term ‘community’ reflect economic and social forces within the CMHC movement and within the broader so- ciety. Much of the book documents the tensions and competition between consensualist social theories and confl- ict theories within the CMHC movement and the impact of broader political and economic forces on this interaction. According to Ken&, consensualist or “priestly” views in- itially defined the role of community mental health as the reaching out of traditional psychiatric medical services to enhance social integration and to treat mental illness in the community. At the opposite extreme, a pure conflict or “prophetic” view perceived community mental health ser- vices as a potent mechanism for undermining a capitalist system that produced mental illness by sacrificing the well- being of non-dominant classes in order to serve the interests of the ruling class. Following an introductory chapter, the book begins by presenting a brief comparison and contrast of models of applied social theory derived from consensual- ist and conflict perspectives. This is followed by social- historical examinations of social psychiatry and of the CMHC movement. Kenig has identified three historical phases in the CMHC movement and she evaluates the meaning attached to ‘community’ in the context of battles and compromises between these conflicting views within the political and economic context of each phase.

The bulk of the book is devoted to discussion of the three phases of the CMHC movement and scrutiny of the mean- ings ascribed to community in each phase. The first phase,

from the late 1950s to the mid 196Os, was one of growth and expansion funded from surpluses within the state sector of the economy. It was characterized by a strong consensualist view in which communities were perceived as geographically defined ‘catchment areas’, without attention to economic, political or cultural issues. Some authors even used the term ‘community’ to refer to local physicians who could benefit from their expert services, implying that patients were not part of the ‘community’ being served.

The second phase identified by Kenig coincided with the period of social unrest that extended from the mid 1960s until the early 1970s. Within the broader context of social activism, the priests of the CMHC movement were chal- lenged by prophets whose conflict theory orientation led them to challenge even the most basic assumptions about mental health, the nature of mental illness, and the goals and methods of mental health services delivery. Kenig describes the works of Richard Kunnes by noting, “here the assump- tion is that psychiatrists represent simply one set of con- trollers, joining with other control agents in order to uphold the culture of an elite group.” “. These (CMHC) programs maintained the establishment’s status quo. They depoliticized issues, ‘psychiatricizing’ them instead” (p. 135). Prophetic views promulgated during this phase saw ‘community’ as defined by common political and economic interests. Community health required community awareness and the community’s control of its own political, social and economic realities. Thus, to reformers applying conflict theory, ‘community’ was defined by the class struggle. Despite a battle for control of the movement between the consensualist and conflict perspectives, the CMHC move- ment continued to grow through most of this second phase, in part by translating societal unrest into a mandate to expand in order to serve a more diverse clientele.

Kenig’s third phase coincided with greater austerity in federal spending and is described as one characterized by the broader social theme of ‘accountability’. Good intentions were no longer accepted as justification for government funding and the CMHC movement became subject to pressures to prove its worth. Program evaluation became formalized and ideological debate was suppressed and sup- planted by atheoretical critiques and consumerist move- ments focusing on improving services delivery. According to Kenig, definitions of community typically returned to a consensualist base, incorporating more diverse consensualist models but usually ignoring the concepts of community inherent in conflict theor&

From Kenia’s perspective, the CMHC movement effec- tively ended in the early 1980s when Reagan’s block grant programs mandated the return of outpatient mental health services to local control. Reagan’s defederalization often channeled paying patients into the profit sector and in many areas of the nation abandoned poor patients to the streets. Kenig states that the concept of community largely

Book Reviews 1587

disappeared from the mental health literature at this time. This certainly seems consistent with the emphasis on indi- vidualism and self-interest that characterized much of the popular and political writings of the 1980s.

The book ends with a brief chapter that attempts to apply a sociology of knowledge perspective to applied sociology. Its conclusions, interesting-if a bit mundane, are that competing and incompatible social theories coexist in their application outside their disciplines, and that while no one theory completely supplants its competitors, theories that serve dominant political and economic systems are usually favored. As macro social and historical changes occur, the frequency of application and relative degree of influence shifts among competing theoretical approaches. Kenig con- cludes that it is these macro political and economic forces and not scholarly discourse that determine the relative power of competing applications of social theory.

A review of this book would be incomplete without one final, nontraditional criticism. While it may be atypical to comment on issues of spelling, usage and proofreading in anacademic book review, an exception must be made here because this book is so rife with careless editing errors that

the author’s meanings are often clouded. Examples range from obvious misspellings “confrontatins” (p. 175) to ap parent misuse of spell checking software to substitute incor- rect words, e.g. “. . to reflect the emerge of interested groups” (p. 201) “. . . a graduure evolutionary process was needed” (p. 162) and (my favorite) “. . . the Me&l Patients Liberation Project” (p. 192) (italics added for emphasis). Indeed, the result is often entire sentences that are non sequiturs: “The idea that disequilibrium, conflict, and change are endemic to the given system, are in fact is basic social process, is not considered” (p. 109). The frequency of such errors throughout the book adds a level of confusion and irritation for the reader that is unacceptable and demands better performance from the Series Editor and/or publisher. Such sloppiness seems especially inappropriate when such a small paperback book is priced at over $20. The topic, the author’s scholarly efforts, and the purchaser each deserve better.

University of Florida Gainesville FL 32610, U.S.A.

LEEA. CRANDALL

Native Society and Disease in Colonial Ecuador, by SUZANNE AUSTIN ALCHON. Cambridge University Press, Cambridge, 1991. $39.95, 151 pp.

In 1992, Eric Wolf challenged anthropologists to study more deeply the historical events that have shaped the lives of the populations this discipline has traditionally studied. In relation to New World indigenous populations, a particu- larly critical aspect of study is the history of disease and its social and cultural effects. These issues have been explored for a variety of other New World populations by archaeol- ogists, physical anthropologists, and ethnohistorians. In this case, Suzanne Austin Alchon, a historian, has undertaken the task of clarifying these issues in the context of colonial Ecuador. The focus is on the relationship between indige- nous peoples of northern Ecuador and disease, particularly those diseases introduced in the sixteenth century by Eu- ropeans. She seeks to demonstrate the biological adapta- bility and resilience of the indigenous populations, and ultimately to show how the history of biological adaptation reveals much about people’s political and social experience under colonial rule.

native population, as well as the development of new social institutions and customs to cope with the demands of the colonial government. A particularly interesting section of this chapter discusses changing concepts of disease in native society. It was considered that now both the European and the native gods had the potential to inflict disease; thus, two sets of rituals were developed.

The 1690’s, however, brought new epidemics, as well as natural disasters, with serious demographic and economic effects. The eighteenth century was characterized by a declining Indian population and a shrinking economy. However, this period also reflected the development of immunological resistance among the indigenous population to some of the illnesses introduced by the Europeans. Concurrently, an increase in native opposition to colonial rule is seen, related to the increasing demands placed by the colonial authorities on a much reduced Indian population. It is suggested that native healers played an important part in organizing this opposition.

The first chapter addresses the pre-colonial situation, with emphasis on social and physical setting, as well as a demographic history of the area before the Spanish con- quest in 1534. The recent Incan conquest of parts of Ecuador had caused some declines in population, as had epidemics of European diseases which occurred as early as 1524. The next chapter examines indigenous concepts about health, illness, and healing. Illnesses were seen as the result of biological and cosmic imbalances, and cures focused on restoring the system to equilibrium, through the use of offerings to the gods, rituals and medicinal plants.

The author concludes that in order to understand the colonial history of the indigenous people of Ecuador, it is necessary to understand the relationship of their biological experiences and their political and social his- tory. Illness was in these situations, not only physiological but also political. The issue, she states, is that disease introduction itself, is not a factor sufficient to itself explain the dramatic decline of Indian populations. Rather, it was the combination of disease and the simultaneous loss of control over economic and social resources which was critical.

The next issue addressed is attempts by the Europeans to deal with illnesses in the sixteenth century, both in their own and in the indigenous population. These included the devel- opment of policies and laws to protect public health, as well as the establishment of hospitals. High levels of mortality in the Indian communities were related not only to the Euro- pean diseases themselves, but also to malnutrition, mistreat- ment, declines in fertility, and the breakdown of traditional indigenous systems of social services. The seventeenth cen-

In general, the book is well written, and the argument and documentation clear. A more serious flaw is the extent to which the author’s final point about the role of loss of economic and social control of resources is not developed as fully as would have been optimal. Nevertheless, the book will be of value to a variety of scholars. Medical anthropol- ogists concerned with contemporary issues of health in Ecuador will find much of use, as will scholars more generally concerned with the issue of the role of illness in cultural and social change.

University of South Florida ROBERTA D. BAER tury, discussed in Chap. 4, was a period of recovery for the Tampa, FL 33620, U.S.A.