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Critical Issues in Rural Health edited by Nina Glasgow, Lois Wright Morton, Nan E. Johnson (Blackwell Publishers) A large sector of the U.S. population—about 22 percent of Americans, or approximately 55 million people—are considered "rural" residents. These people face a unique set of health issues: they experience social, cultural, and economic disadvantages that can increase their risk for adverse health consequences. 

The first text of its kind, Critical Issues in Rural Health provides a comprehensive sociological study of rural health and health care trends in the United States, by examining the health and well-being of rural populations at all stages of life. Editors Glasgow, Morton, and Johnson present integrative reviews of theory and research on rural health issues, with the most up-to-date statistics and findings of empirical research. This informative and groundbreaking text goes beyond the scope of previous studies and emphasizes differences between rural and urban areas in health and health care. Surprisingly little research has examined the differences in disability and mortality rates by residence or degree of rurality—this book does. In addition, contributing authors report on the impact of age or life stage, race and ethnicity, social class, rural occupations, and community structure on various health issues.

Historically, health status has been lower and health care services more limited in rural than urban areas of the United States. The reasons are complex and changing even as rural populations and conditions change. In some areas the health of rural and urban populations is converging; in other areas health disparities among rural and between rural and urban have remained the same or increased. We are members of the Rural Health Interest Group (RHIG) of the Rural Sociological Society (RSS), and this book grew out of conversations about the changing health of rural people with other sociologists in the RHIG. Our discussions centered on the lack of a body of work that examined the critical health and health care issues facing rural people and places. Many of our authors are members of the RHIG of the RSS. They have studied rural people and places over many years and seek to understand factors that influence disease, health, and well-being.

The purpose of this book is to address topics critical to understanding health conditions and trends among people and communities of the rural United States. We bring a sociological perspective to the study of rural health. Chapter authors present integrative reviews of theory and research on rural health and health care, as well as up-to-date findings from empirical research. Contributors also examine the implications of theory and research for public policy and intervention.

Throughout the book we investigate health-related differences and similarities between rural and urban areas and among subgroups of the rural population. A special feature of this volume is the section on health disparities among rural minorities and other disadvantaged groups. Past research has taught us that, regardless of place of residence, minorities have lower health status than does themajority non-Hispanic White population. But prior research has not provided in-depth investigations of how rural residence interacts with minority/disadvantaged status to affect health outcomes for those groups. How race/ethnicity, social class, region, age, life course stage, rural occupations, and gender affect rural health outcomes presents important themes throughout the book, not simply in the chapters on health disparities among minorities and other disadvantaged groups.

The contextual and social structural attributes of rural communities affect individual and population health. Some chapters focus on factors that threaten rural residents' health, while others examine factors offering promise for improvements in rural health. Positive health outcomes may result from the provision of innovative health care and community structures that promote pluralism and collective efficacy, as well as health-enhancing social relationships and behaviors of individuals. A focus on health and wellness rather than solely on illness and illness care is important because this is where we are likely to discover pathways to better health. Improved health status among rural Americans would likely reduce health care expenditures, and it would surely improve the quality of life and productivity of the population.

The book is organized into several parts. Following the introduction, the section on morbidity, disability, and mortality overviews rural/urban spatial patterns in these health indicators. In the next section, chapter authors investigate challenges to rural Americans' health relative to injuries and fatalities associated with rural occupations, environmental pollution, mental illness, health-risk behaviors of rural youth, food insecurity, and rural diet/nutritional deficiencies.

The section on health disparities includes chapters on rural American Indians, African Americans, Latinos, migrant farmworkers, and Appalachians. These groups experience some of the lowest health indicators and greatest barriers to health care access of any rural Americans. The concentrated poverty and underdevelopment of their communities present special challenges to raising the health status of the U.S. rural population.

The book then turns to the health care system of the rural United States and includes chapters on health insurance coverage, health care funding, rural health networks, telemedicine. and long-term care. This section includes discussions of health care services and the potential for newer, innovative services to address inadequacies in the formal health care system of rural America. Next, theoretical perspectives on improving population and individual health in rural areas are offered. Finally, the concluding part reviews major themes and findings that emerged from the preceding chapters and draws from those policy and programmatic implications related to critical issues in rural health.

 

 

Unhealthy Health Policy: A Critical Anthropological Examination by Arachu Castro, Merrill Singer (Altamira Press) (Paperback) This new collection turns a critical anthropological eye on the nature of health policy internationally. The authors reveal the prevailing social inequalities that often represent significant threats to the health and well being of the poor, ethnic minorities, and women. The authors define an anthropology of policy concerned with decision-making and the impact of health policy on human lives. It will be a critical resource for researchers and practitioners in medical anthropology, medical sociology, public policy, and public health care.

Excerpt: This book is organized into three sections. Part 1, "International Institutions and the Setting of Health Policies," demonstrates the distance between health policies that are conceptualized by international institutions and the reality of these poli­cies on the ground, particularly throughout Latin America, Africa, and Asia. Of-ten, these strategies reflect an ideology that does not necessarily respond to the needs of the people for whom they were designed. The chapters offer insightful perspectives on whose interests are served by current health priorities and policies. Chapter 1, by Paul Farmer and Arachu Castro, analyzes the increasingly disproportionate weight of economic arguments within the context of establishing priorities in the fight against AIDS. By examining the cases of two neighboring countries in the Caribbean—Haiti and Cuba—the authors demonstrate and ana­lyze significant differences. In Haiti, a series of obstacles to the delivery of pub­lic health services can be attributed to the abuse and misuse of cost-effectiveness tools and to politicized arguments within the international community on the al-location of external resources to impoverished countries. Conversely, the Cuban case reflects self-determined health policies and resource allocation practices that generally follow and are shaped by the epidemiology of the disease. In chapter 2, Francisco Armada and Caries Muntaner analyze the role of international financial institutions in the reform and increased privatization of health systems in Latin America. The authors argue that this trend, part of the broader neoliberal agenda, primarily benefits national and transnational corporations, thereby reproducing and reinforcing already existing social inequalities. 1n chapter 3, James Pfeiffer ex­plores the damaging fragmentation of health services in Mozambique, a direct consequence of structural adjustment policies set by multilateral and bilateral funding institutions. Joan Paluzzi, in chapter 4, reminds us of the I978 Declaration of Aima Ata, which reinforced the importance of primary health care sys­tems, and argues that international institutions continue to privilege restricted, vertical programs at the expense of primary programs. By exploring the Chilean case, Paluzzi demonstrates the interdependence that exists between these two health care delivery models.

1n chapter 5, Fouzieyha Towghi analyzes the misguided attempts to integrate traditional midwives into primary health care in Pakistan, and the resulting devalu­ation of this human resource as a potential collaborator in the reduction of ma­ternal mortality and morbidity. In chapter 6, Salmaan Keshavjee focuses on the implementation of a revolving medicinal drug fund in post-Soviet Tajikistan. Through the prioritization of privatization, the revolving drug fund has actually in-creased inequalities in access to medicines. In chapter 7, Alice Desclaux explores the impact of user fees on AIDS treatment in Senegal. 1n addition to the damaging im-pact on the financial capacity of households, user fees also have become an important factor in the pattern of decreasing drug adherence. 1n chapter 8, Arachu Cas­tro analyzes the integration of reproductive health services in Mexico. Within the context of promoting contraceptive use as part of the routine birthing experience, health professionals often endorse broader, dominant population policies; as a re­sult, some indigenous women are reluctant to deliver in hospital settings, thus in-creasing their risk for untreated obstetric complications. In chapter 9, Imrana Qadeer and Nalini Visvanathan examine some of the underlying issues that shape population policies in India, and link them to the trends toward the general priva­tization of health care and the marginalization of primary health care.

Part II, "National Health Policies and Social Exclusion," explores the impact of national health policies on the most disadvantaged people within countries in Latin America, Europe, and North America. Specifically, the chapters in this section reveal the ways in which health policies have contributed to the construction and mainte­nance of significant social inequality and related human suffering. Moreover, the chapters in this section call attention to health policies that can be beneficial for one group while punishing another—often less privileged—group within society. For this reason, and as documented by the chapters that follow, health policies can become in-tended or unintended implements of structural violence. Collectively, these chapters provide textured and historically rooted accounts of how health policies can create vulnerable social groups and put them in harm's way rather than protect the poor, women, or people of color. In chapter 10, César Abadía-Barrero analyzes the suc­cessful implementation of access to health care—including comprehensive AIDS care—education, and other social opportunities for children who live with HIV/AIDS in Brazil. Because poor children, many of them living on the streets, do not usually have access to these services, being HIV-positive has become a social ad-vantage. Exemplary is Katherine Bliss's analysis, in chapter I 1, of the gendered history of syphilis prophylaxis popularization in revolutionary Mexico, including the 1940 criminalization of infection transmitted through sexual contact. In chapter I2 Linda Whiteford and Graham Tobin, based on studying the lives of Ecuadorian people displaced by the eruption of a volcano, argue that emergency evacuation and resettlement policies have actually increased their risk of illness and disease. In chapter 13, Didier Fassin analyzes political choices that, despite the existence of a universal health sys­tem, contribute to the increase in health inequalities in France, predominantly among immigrant populations. In chapter 14, Kristen Jacklin and Wayne Warry explore Canadian policies that were designed to enhance self-determination in health care for First Nations peoples but that, in practice, have had very limited benefits for Abo­riginal health. In chapter 15, Sarah Horton focuses on the attempts of the U.S. gov­ernment to reduce the number of people without health insurance through managed

care, and how these attempts actually decreased the number of Latinos eligible for federal health insurance in New Mexico. In chapter 16, Cathleen Willging, Howard Waitzkin, and William Wagner assess how other attempts at managed care to reform the provision of health services to the poor in the United States decreased access to mental health services in rural New Mexico. In chapter 17, Claudia Chaufan analyzes the social construction of the diabetes epidemic in the United States, and discusses how the commodification of health care and the impact of broader social inequali­ties have contributed to a failure to adequately respond to the needs of diabetics.

In chapter 18, David Buchanan, Merrill Singer, Susan Shaw, Wei Teng, Tom Stopka, Kaveh Khoshnood, and Robert Heimer examine the implications of poli­cies on access to sterile syringes and how they can directly contribute to a de-creased incidence of HIV among injecting drug users. The authors compare these policies between Connecticut, where a needle-exchange program exists, and the neighboring state of Massachusetts, where the difficulty of procuring a safe nee­dle puts injecting drug users at a higher risk for HIV In chapter 19, Merrill Singer reviews the U.S. War on Drugs, revealing thereby that in practice antidrug policies often serve to promote a war on young men of color while producing a number of "secondary benefits" for the dominant social class. In chapter 20, the final in part II, Philippe Bourgois demonstrates some of the ways in which the War on Drugs has backfired and helped to promote incipient inner-city apartheid.

The third and final part of the book, "Impact of Policy on the Practice of Medicine," focuses on the health care system and the role of policy makers in neg­atively shaping health care delivery. Chapter 21, by Hans Baer, examines the role of policy in the co-optation of alternative healing as a subordinate system to biomedicine. Chapter 22, by Robbie Davis-Floyd, focuses attention on the ways the health care industry is shaped by health policy, with special reference to recent trouble-filled and stressful interaction between health care providers and midwives. Chapter 23, the final chapter, asks why high-tech medical intervention rather than prevention is the focus of breast cancer policy in the United States. Ironically, the author, Catherine Hodge McCoid, notes that in treating rather than preventing breast cancer, industrial medicine profits from diseases caused by carcinogenic in­dustries.

1f, as Paul Farmer has argued, "inequality itself constitutes our modern plague," then health policy must be directed at outlawing inequality as a public health priority. This, however, has not been the case as documented by the chapters to follow. Indeed, the opposite has often been the case. Recognition of this fact provides direction for an anthropological role in health policy, namely contributing to the making of healthier societies through the making of healthier health policies, induding policies that help to level an often very unleveled playing field. Rules and guidelines designed to equalize the quality of life across social strata and vulnerable subgroups improve access to quality health services for all, allow freedom from structural violence, and would aptly be tided healthy health policy.

Diversity in Health Care Research: Strategies for Multisite, Multidisciplinary, and Multicultural Projects edited by Joellen W. Hawkins and Lois A. Haggerty (Springer Publishing Company) The new gold standard in health care research is conducting studies that are truly representative of the general population – and not limited to a narrow range of cultural, gender, geographic, or socioeconomic groups. Diversity in Health Care Research provides a how-to approach to planning, implementing, and conducting such studies.

The human genome has been completed. We now know that, from a biological perspective, we are almost identical, and that that race is a social construct, not a scientific classification. Yet, incredible disparities in health status continue to exist, many due to gender, race, ethnicity, education, income, disability, geo­graphic location, or sexual orientation. Since these disparities are not due to scientific classification, they may well be due to social classification and issues such as prejudice, discrimination, and lack of access to services.

In order to eliminate disparities and improve health status for all, it is important to understand the complex relationships that lead to these differences. It is, however, critically important to conduct this research in an atmosphere that is respectful of differences, and using research designs that are sensitive to cultural and economic issues among populations. The very nature of this type of work demands that it be conducted by investiga­tors with a variety of disciplinary perspectives, in a variety of settings, and among participants with a variety of backgrounds. Since each individual has a unique ethnic background and a specific disciplinary lens with which she or he views the world, the ability to be successful requires a special set of learned knowledge, skills, and abilities.

Contents include:

Part I – Strategies for Implementation

1. Managing Multisite, Multidisciplinary, and Multiethnic Research Projects - Nancy W. Veeder
2. Obtaining Funding - Mary E. Duffy
3. Facilitating Passage Through the Institutional Maze - Joellen W. Hawkins, Cynthia S. Aber, and Loretta P. Higgins
4. Utilizing Research Assistants - Ursula A. Kelly
5. Special Considerations for Multicenter Research - Joyce M. Dwyer
6. Managing the Multisite Team - Carole W. Pearce
7. International Multisite Studies - Linda J. Mayberry, Anindya K. De, Eleanor L. Stevenson, and Dyanne D. Affonso

Part II – Lessons Learned From Specific Research Projects

8. The Birthweight Study: Challenges of a Multisite, Multicultural Collaborative Research Endeavor - Jacquelyn C. Campbell, Doris Campbell, Sara Torres, Josephine Ryan, Christine King, and Patricia Price Lea
9. Testing the Efficacy of an Intervention Directed Toward Family Caregivers of Cancer Patients: The Family Care Research Program - Sharon L. Kozachik, Barbara A. Given, and Charles W. Given
10. The Women’s Health Initiative: Aspects of Management and Coordination - Barbara Cochrane, Bernedine Lund, Susan Anderson, and Ross Prentice
11. The Early Head Start Research and Evaluation Consortium: Collaborations and Partnerships - Rachel F. Schiffman

Joellen W. Hawkins and Lois A. Haggerty, professors in the William F. Connell School of Nursing, Boston College, have produced a masterful work that will assist researchers to develop the skills and sensitivities necessary for successful research. They and their contributors provide with a broad perspective that is both enlightening and pragmatic. Diversity in Health Care Research will help researchers anticipate and plan for the challenges of conducting research in several sites, from gaining entry to working with clinicians who have competing job responsibilities. Examples of multicultural, multisite studies conducted by multidisciplinary teams provide the reader with a wide range of projects that have successful outcomes. The authors of these chapters provide the pragmatics that demonstrate how the theoretical components come together in actual situations. The book will help us to understand and appreciate differences, celebrate our diversity, and work together to eliminate health care disparities and improve the health of all.

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