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Topics Correspondents
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interdisciplinary studies Belgrade: Balsa Spadijer
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Communications Bustamente
World economy Cairo: Abdel M o n e i m El-Sawi
Canberra: Geoffrey Caldwell
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 international
social science
^^ journal
Published quarterly
by Unesco
Vol. X X I X , N o . 3, 1977

The health of nations

Editorial 365

Sociology of medicine
Derek G. Gill and Medical sociology: W h a t ' s in a n a m e ? 369
Andrew C. Twaddle
Manfred Pflanz and A sociological perspective o n concepts of disease 386
Heinrich Keupp
Monitoring and servicing national health
Amor Benyoussef Health service delivery in developing countries 397
A. S. Hr Strengthening health information services 419
Emile Levy T h e search for health indicators 433
Mikio Yamamoto A n ecological analysis of national health in Japan 464
et al.
Patients and their resort to health care
Manouchehr Mohseni Attitudes towards the use of the medical
and sanitary services in Iran 473
Peter Kong-ming New Traditional a n d m o d e r n health care: an appraisal
of complementarity 483
Anna Titkow S o m e indicators of medical a u t o n o m y in W a r s a w 496

The medical profession

Vilibald Bilek and
Jindrich Balogh Doctors of thefirstline in Czechoslovakia 505
Andrs November
General practitioners in Switzerland 518

T h e social science sphere

Andr Bteille
T h e language of the social sciences 5 5 7
A. E. Cawkell T h e value of citation indexesa c o m m e n t 533
Professional a n d documentary services
Addition N o . 2 to the World List of Social Science
Periodicals 541
Approaching international conferences 553
Materials from the United Nations: an annotated
selection 556
B o o k s received 564

ISSN 0020-8701
 Editor: Peter Lengyel
Assistant editor: Ali Kazaocigil

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Unesco 1977
Printed in France
The health
of nations
 Editorial

While w e have, in the past, devoted considerable attention to different aspects of

mental health, especially in Vol. X I , N o . 1, 1959, o n 'Social Problems of Mental
Health' and Vol. X X V , N o . 3, 1973, on 'Psychology and Psychiatry at the
Crossroads' this is thefirstoccasion on which w e have ventured into the wider area
of medical sociology and the problems surrounding public health. In selecting
subjects for articles and authors w e have benefited from the advice particularly of
Jean-Nol Aquistapace, ISSJ correspondent in Vienna, Professor M a r k G . Field,
Chairperson of the Research Committee on the Sociology of Medicine of the
International Sociological Association, D r P. J. M . M c E w a n , editor-in-chief of the
international journal Social Science and Medicine and of D r Derek Gill, co-author
of the introductory survey. W e wish to thank them for their suggestions and
support.
The broad spectrum covered in the following pages has, of late, c o m e to the
fore rather prominently in a number of social science and more general periodicals.1
If w e have chosen to paraphrase A d a m Smith in our title, this is not only to underline
the notion of health as wealthindeed, in a world-wide perspective, as a scarce and
precious resourcebut also to draw attention to the actual locus of disease. A s
Manfred Pflanz and Heinrich K e u p p remind us in their contribution, it is not only
or necessarily persons w h o are sick: families, groups, institutions, even whole
societies or cultures can be designated as the ultimate seat or carriers of disease, a
matter reflected by c o m m o n parlance in more or less picturesque and precise turns
of speech. N o r must it be forgotten that the sanitary conditions prevailing in
advanced countries, which have dispelled the spectres of pestilence and the constant
threat to survival from the immediate consciousness of their citizens so that disease
can be regarded as exceptional, an interlude rather than a way of life, are far from
universal. The health of nations remains as diverse as their wealth.
The presentation of the articles under subsections is designed both to help
readers to pick their way through the material and to illustrate the variety of
existing approaches (which, of course, are by no means exhausted by the samples
of work we publish here). It is, however, perhaps worth pointing to some parallels
between efforts in the analysis of the social problems of health and other areas, which
show certain significant confluences. The opening article by Derek Gill and Andrew

Int. Soc. Sei. J., Vol. X X I X , N o . 3, 1977

366 Editorial

Twaddle reminds us of the roots of medical sociology in the general inquiries into
social conditions conducted in the nineteenth century and its subsequent subordi-
nation to the interests and orientations of the medical profession. Several other
branches of sociology have a similar history, especially those which (like the
sociology of education or law) concernfieldswhere the practitioners either preferred
to develop their o w n sociology 'from within' or resisted such approaches vigorously.
The article by Manfred Pflanz and Heinrich K e u p p , moreover, constitutes a
persuasive example of what a mature sociology of medicine has to offer, especially
by w a y of wider cultural horizons and evidence drawn from neighbouring disci-
plines, like anthropology and history, and equally utilized by Peter K o n g - m i n g N e w
in his comparison of traditional and modern health care.
The section o n monitoring and servicing national health groups four contri-
butions linking health care with policy and planning concerns. A s for other social
services one here immediately encounters the familiar dilemmas of resource
allocation, indicators, information bases and criteria for striking a balance between
needs and available facilities. Readers wishing to pursue such matters m o r e broadly
might refer back to our issues on 'Socio-economic Indicators: Theories and
Applications' (Vol. X X V I I , N o . 1, 1975) and 'Economics of Information and
Information for Economists' (Vol. X X V I I I , N o . 3, 1976).
The third section, on patients and their resort to health care, focuses on the
consumer and the options open to him. It is no coincidence that these contributions
recall other kinds of consumer studies and surveys of behaviour, while equally
drawing attention to facets of what has rightly been called 'the bureaucratization of
medicine' and its consequences. Throughout the second and third sections, further-
more, there runs a thread of argument and logic which will be very familiar to those
acquainted with the literature on technological choice and the principles underlying
the division of labour. In medicine, as in industry, in agriculture, even in teaching,
there are more or less capital-intensive possibilities which directly govern not
only institutional and organizational patterns but the very allocation of tasks and
hence the training and subsequent levels of responsibility. It is clear that here,
too, the direct transfer of models from developed to developing countries must be
approached with caution and that there is considerable room for imaginative inno-
vation. It m a y be added that in n o other domain is a combination of daring and
caution so crucial, as a number of recent successes and failures with drugs, surgery
and the control of infectious disease have shown.
The fourth and last section returns to a classic subject, the relations between
patients and doctors, especially those closest to the public, that it to say, general
practitioners. It is a theme m u c h explored also in literature since it has all the
makings of popular appeal, as the success of such plays as George Bernard Shaw's
The Doctor''s Dilemma or Jules Romains' Dr. Knock and international best sellers
by and about doctors like A . J. Cronin's The Citadel or Axel Munthe's The Story of
San Michle amply demonstrates. A recent issue of this Journal (Vol. X X V I I ,
 Editorial 367

N o . 4, 1975) which dealt with 'Professionalism in Flux' contains related material,

especially the article on 'The Doctrine of the Professions: Basis of a Power
Structure' by Gabriel Gyarmati K . , which usefully complements the empirical
contributions from Czechoslovakia and Switzerland in these pages.
P. L.

Note

A n international conference on medical sociology from Derek Gill, whose address is to be found
took place in Paris on 6-9 July 1976. Infor- on page 369.
mation on contributions m a y be obtained
 Sociology of medicine

Medical sociology: What's in a name?

Derek G . Gill and Andrew C . Twaddle

Medical sociology is today a relatively n e w but rapidly expanding specialism in the

discipline of sociology. Currently the Medical Sociology Section of the British
Sociological Association is the largest specialty group, running its o w n annual
conference and other regional meetings. In the United States the credibility of
medical sociology is high, and the present executive officer of the American
Sociological Association is a medical sociologist. The Research Committee on
Medical Sociology of the International Sociological Association is the third largest
Research Committee and has sponsored a whole series of international meetings
and subsequent publications which have facilitated both personal and intellectual
exchanges between medical sociologists from all over the world.
Nevertheless the definition of medical sociology and the identification of
medical sociologists is not a simple task. Goffman's book, Asylums: Essays on the
Social Situation of Mental Patients and Other Inmates,1 was based on research which
was completed and published while he was a professor of sociology at Berkeley
but neither he nor his peers would label him today as a medical sociologist. While it is
difficult to provide absolute proof it seems reasonable to assume that Goffman's
brilliant analysis and criticism of mental hospitals in the United States did m u c h
to enhance the pressures towards the reform of mental institutions both in the
United States and elsewhere. Brian Abel-Smith's latest work is entitled Value for
Money in Health Services: A Comparative Study" and was preceded by works on the
history of nursing and of British hospitals. These works embrace sociological
perspectives in relation to health care and Abel-Smith has been consultant and
adviser to a number of governments w h o were concerned to develop, expand or

Derek G. Gill is Associate Professor and Chief of the Section of Behavioral Sciences at the School
of Medicine, University of Missouri-Columbia, TD3-W Medical Center, Columbia M O 65201
( United States). He is a sociologist who previously held appointments at the University of Aberdeen
(Scotland) and has published articles especially on illegitimacy, sex education and adoption, and
a book T h e Other Side of the Wedding Ring (1976).
Andrew C. Twaddle is Associate Professor of Sociology and of Community Health and
Medical Practice at the University of Missouri. He has published articles on illness behaviour and
hospital admissions and is completing a textbook on the sociology of health in collaboration with
R. Hessler.

Int. Soc. Sei. J., Vol. XXIX, N o . 3, 1977

370 Derek G. Gill and Andrew C. Twaddle

improve their health care systems. M a n y m o r e examples of persons w h o have, at

various times, written and researched on medical problems from a variety of social
science perspectives could be quoted, yet they would not describe themselves or be
labelled by others as medical sociologists. A n y attempt to identify all such indi-
viduals would probably be exhausting as well as not very productive. O u r intentions
here are to: (a) review, albeit somewhat perfunctorily, the major tasks which
medical sociologists have identified in their research, service and teaching activities
and to relate such activities to the work of other social scientists, medical prac-
titioners, historians and so o n whose contributions are pertinent to the further
development of medical sociology or have already had a significant impact upon
the discipline; and (b) c o m m e n t upon neglected areas of research in medical soci-
ology with special reference to the apparent disjunction between health and illness.

The development of medical sociology

In both Europe and the United States the emergence of medical sociology as a
separate and identifiable subdiscipline dates from the period immediately following
the Second World W a r . Nevertheless, to anticipate for a m o m e n t our subsequent
argument, the roots of medical sociology are very m u c h older but w e will first
analyse the trends and characteristics of the discipline in the last thirty years before
attempting to place the specialty in its broader, socio-historical and political
perspective,
In August 1976 at an international seminar on training programmes in
medical sociology organized by Y v o Nuyens of the University of Louvain
(Belgium) and sponsored by the Medical Sociology Research Committee of the
International Sociological Association, S. B l o o m presented a paper entitled, 'The
Profession of Medical Sociology in the Future: Implications for Training Pro-
grams', 3 which contained a most significant and important analysis of the recent
history of medical sociology providing a most appropriate framework for our task.
In an earlier presentation at an International Sociological Medical Sociological
Conference held in Jablona (Poland), Bloom, in commenting upon the situation
in 1973, stated:1

Another striking feature of the time for the United States was the pressure for change
towards policy science. Medical sociology appeared to emerge from one identity to assume
another: from a scholarly profession, it was becoming more applied. At the same time,
Europe presented a picture of quite different development, essentially the reverse. From
origins in policy and planning, the medical sociology of Europe seemed to be moving
towards a more academic balance.

Bloom then went on to present an outline of the development of American medical

sociology from the period immediately following the Second World W a r u p to the
 Medical sociology: What's in a name? 371

present emphasizing the part played by research funding by both private foun-
dations and governmental agencies. A s well as funding basic research, the grant-
giving bodies, initially especially the private foundations, provided support for the
development of training programmes to increase the n u m b e r of medical sociologists.
Research and teaching tended to go hand-in-hand and B l o o m , after reviewing the
writings of American medical sociologists in the 1950s and 1960s, suggests that a shift
from a micro- to a macro-sociological perspective is discernible over this period.
Schematically this trend is depicted below. 5

From
A social psychological frame of
reference
Small-scale social relations as subjects
of research
Role analysis in specifically limited
settings
Basic theoretical concerns with classic
social analysis of behaviour
A perspective of h u m a n relations
and communication
To
Institutional analysis
Large social systems
C o m p l e x organizational analysis
Policy science directed toward
systematic translation of basic
knowledge into decision-making
P o w e r structure analysis

In August 1974, at the Fourth International Conference on Social Science and

Medicine at Elsinore ( D e n m a r k ) , R a y m o n d Illsley reflected u p o n the development
of medical sociology in the United K i n g d o m , giving his plenary address the title,
'Promotion to Observe a Status'.6 Illsley traced the development of British medical
sociology via a process in which, initially, sociologists became involved in medical
research through collaboration with medical scientists. In the early stages the
definitions of problems and research issues s t e m m e d from the interests and concerns
of medical practitioners rather than social scientists. T h e situation was reminiscent
of that classic distinction drawn by Strauss' in the early 1950s between sociology of
and sociology in medicine. Illsley described the situation in the following words: 8

W h e n access to medical locations was rare or unobtainable, the major data sources
consisted of medical statistics primarily of mortality because morbidity statistics on
representative populations were scarce and k n o w n to be unreliable or subject to great
difficulties of interpretation. Even access to medical records in hospitals and clinics
involved similar problems unless one could study atfirsthandthe process by which they
were generatedearlier workers were perhaps less overtly aware of this problem because
they antedated the work on records as accounts in justification. Whether medical statistics
or records, the primary methodological approach, given the data, was epidemiological.
Research projects usually implied interdisciplinary teamwork because sociologists were
incorporated into pre-existing teams to supplement with their skills an on-going program
372 Derek G. Gill and Andrew C. Twaddle

on medical research. More importantand this was a great deterrent to social scientists
sensitive of their lowly statusthe research objectives were formulated and usually the
basic designs laid down by medical scientists operating within the framework of their o w n
models, clinical responsibilities and career structures. Such work nevertheless provided
contacts, the opportunity for a widening role and insights into the major medical insti-
tutions, problems and data... Undoubtedly the radical differences n o w are (a) that sociol-
ogists have obtained access to medical settings and (b) that they increasingly obtain access
for projects and purposes of their o w n formulation.

Illsley's conclusion therefore is that medical sociology has n o w c o m e of age through

gaining a greater degree of independence from a situation which was originally
controlled by, and reflected the interests and concerns of, medical practitioners
rather than social scientists.
Atfirstsight this analysis would seem to contradict Bloom's earlier contention
of a different etiology of medical sociology in Europe and the United States, with
European medical sociology based at least in thefirstinstance on research issues
that apply to policy concerns and with a later shift to more academic orientations
reflecting the interests of medical sociologists rather than as an applied sub-
specialism. But as Illsley was quick to point out, the earlier stages of collaboration
between social scientists and medical practitioners tended to involve epidemiological
and survey research investigations. Morris" has argued that epidemiological inves-
tigations are one of the essential basic techniques for the examination of social
policy issues. Illsley began his career in medical sociology in the Obstetric Medicine
Research Unit of the University of Aberdeen's Medical School. This unit, under
the direction of Sir Dugald Baird, focused its major research interests on the
relationships between social and biological factors in the epidemiology of h u m a n
reproduction. Baird himself had been influenced by Richard Titmuss and by Sir
John Boyd Orr and the staff of the Rowett Agricultural Research Institute and both
authorities were intensely aware of the inextricable mix of social, environmental a n d
biological factors in the processes of pregnancy and parturition. T h e findings of the
research team culminated in the development of improved maternity services in the
city of Aberdeen and subsequently the introduction of an area-wide maternity
service which provided medical care for pregnant and parturient w o m e n of the
highest level throughout the north-east of Scotland. While the researchfindingswere
the major rationale underlying these developments, their implementation was m a d e
possible only through the existence of the British National Health Service which
facilitated the spread of the influence of a teaching and research department across
the total service area. Other n o w established medical sociologists such as Margot
Jefferys and A n n Cartwright c o m m e n c e d their careers in a very similar fashion,
through close collaboration with medical practitioners in epidemiological and survey
research investigation. Bloom's c o m m e n t that the growth of European and British
medical sociology reflects trends almost the reverse of the American situation, with
its initial concern with specific rather than generic issues, is clearly worthy of further
 Medical sociology: What's in a name? 373

investigation. This apparent contrast suggests the further question: A r e w e yet in

a position to define exactly what is medical sociology and once having answered or
attempted to answer that question, to ask further, w h e n in point of historical fact
did people begin to address issues which w e would n o w accept as being medical
sociology in emphasis or content?

Medical sociology and social medicine

The suggestion has already been m a d e that the roots of medical sociology go back
very m u c h further than the period of rapid expansion of twenty-five to thirty years
that followed the end of the Second W o r l d W a r . T h e diversity in recent years in the
development of medical sociology in Europe and in North America m a y therefore
reflect the different historical and intellectual traditions that operate in the old and
the n e w world.
A clue to the resolution of both problems outlined abovewhat is medical
sociology and w h e n did concerns of a medical sociological nature initially
originateis to be found in thefirstparagraph of Pflanz's and Siegrist's paper
entitled, 'Basic Assumptions in Teaching Medical Sociology in Medical Schools:
The Case of Western Germany': 1 0

Even if the term medical sociology has not been used in Germany before 1955, the matter
itself has a long tradition in German medical thinking. . . . [We shall not attempt] to
delineate the whole development of thinking in an area which today we would call medical
sociology but it has to be mentioned that the writings of Virchow and Salamon Neumann
(around 1848) belong to the classics of medical sociology. Another example is the book by
Mueller-Lyer of 1914 about sociology of suffering. About the same time a more pragmatic
approach had been chosen by Alfred Gortjahn, the great m a n of German social hygiene
w h o emphasized the necessity of a marriage between social hygiene and sociology and
economics. It also must not be forgotten that the Swiss H . E . Siegrist was already using the
sociological approach to the history of medicine when he was teaching at Leipzig just as
he did later in the United States. The most influentialfigurefor one generation was pro-
bably Viktor von Weizscker w h o was one of the most important promoters of medical
sociology and psychomatics in Germany beginning with the early thirties until the years
after World W a r D .

In essence, Pflanz and Siegrist are suggesting that medical sociology is very m u c h
older than it would seem to be. Reference to Edwin Chadwick's pioneering report
on the sanitary conditions of the labouring population in England in 1842 should
m a k e this clear.11
Today w e would describe Chadwick's work as a carefully prepared statement
of the health care needs of specific urban communities based u p o n empirical
research. H e described specific techniques in the form of sanitation, hygiene, clean
374 Derek G. Gill and Andrew C. Twaddle

water supplies, which would ameliorate or eradicate the conditions he described

and thereby reduce the incidence of illness and disease in the nation. H . Jack
Geiger's work in Bolivar County in the Mississippi Delta1* in the late 1960s and
early 1970s is strikingly reminiscent of Chadwick's orientation. Chadwick's
proposals were not fully implemented until the last quarter of the nineteenth
century in the United K i n g d o m since they had to attract sufficient public support
before they could become a political reality. Between 1866 and 1872 the sessional
proceedings of the National Association for the Promotion of Social Science
frequently dealt with issues concerning health care needs, sanitation, hygiene and
the extension and development of medical provision. Earlier in the 1850s, the
papers of the Social Science Association often devoted m u c h attention to similar
concerns. Indeed, the social history of the nineteenth century is replete with
examples of the introduction of reformist and radical measures aimed at improving
the general status and condition of the population. But above all, the principle
gradually became established that it was the responsibility of at least some members
of the intelligentsia to take on the duty of challenging the values and ideological
assumptions of the Establishment towards issues of social policy. In British social
history, it was soon accepted that social epidemiological and survey research data
was an important element in the development of reformist attitudes and subsequent
legislative and administrative change.
Social scientists in the United K i n g d o m and in Europe therefore became
involved relatively early in the process of social reform, if not directly involved in
political action. Sidney and Beatrice W e b b were convinced that the process of social
reform rested upon the generation of data and the distribution of social facts which
would ultimately speak for themselves in producing the requisite motivation for
reformist legislation or administrative action. While the motivation of the
architects of the Education (School Meals) Act of 1906 was certainly mixed, the
findings of Charles Booth and B . Seebohm Rowntree concerning the almost
inevitable relationships between poverty, malnutrition and disease were important
forces in persuading the Establishment to introduce a measure whose purpose was
to improve the nutritional status of young people. A critical and reflexive posture in
the development of European and British social science was maintained in the 1920s
and 1930s through the work of R . H . Tawney, G . D . H . Cole, Richard Titmuss, Sir
John B o y d Orr, William Beveridge, Victor Gollancz and the Left B o o k Club and
so o n . While this tradition m a y have been submerged to some extent in the years
following the Second World W a r as medical sociology was beginning to develop,
nevertheless the critical and reflexive posture of m u c h British epidemiological and
social survey research is readily apparent in the work of Illsley13 and his colleagues
in Aberdeen and in Cartwright's14 studies of various aspects of the National Health
Service.
Bloom's analysis of American medical sociology in the period following the
Second World W a r is very specific in that a social policy orientation is a relatively
 Medical sociology: What's in a name? 375

recent development in the discipline on the American continent. With rare

exceptions, such as the Committee on the Cost of Medical Care which achieved some
degree of notoriety in the 1930s, it was very difficult indeed to identify critics of the
health care system in America like those so characteristic of European and British
medical sociology. W h a t are the factors that m a y be associated with this difference
in orientation?
It m a y reflect the different development of the intellectual tradition in North
American and European cultures. Herbert Spencer, a Social Darwinist and the
apologist for unbridled competition and laissez-faire capitalism, was teaching and
delivering invited lectures on the American university circuit long after his work
had been rejected and forgotten in Europe. His doctrine was m u c h more compatible
with the individualistic orientation and value system of American society than it
was with the beginnings of the collectivist philosophy which emerged in European
society about 185 years ago, promotedfirstby the French Revolution of 1789 and
gradually developing increasing support throughout the nineteenth and twentieth
centuries. T h e reformist tradition w a s incorporated into the activities of early
nineteenth-century social scientists almost as soon as social scientists became
identifiable. In the w o r k of M a r x and Engels, Saint-Simon and T h o m a s Paine, a
more activist orientation was developed which continued to attract minority support
in Western European circles throughout the nineteenth and twentieth centuries. O n
the other hand, a very different orientation and tradition would seem to have
prevailed a m o n g the American intelligentsia. Certainly immediately following the
Second World W a r there were relatively few American sociologists w h o were
critical of the Establishment or w h o were radical in orientation. The most notable
exception, of course, would be C . Wright Mills. It is also perhaps worth remembering
that the United States of the early 1950s enabled McCarthyism to develop and to
attain a grip on social and political institutions. McCarthy was able to destroy the
careers of persons as diverse as obstetricians or gynaecologists andfilmstars simply
by labelling them 'Communists'. M o r e generally, any radical or even mildly
reformist position could be destroyed by invoking the label 'Communist' or
'Fellow Traveller'. Without a strong tradition of intellectual challenge to Estab-
lishment thought and policies, what were early American medical sociologists to do?
In such a situation they were not in a position to conduct policy-based research,
except indirectly. A s a consequence, they m a y have been tempted to concentrate, in
both teaching and research, upon 'safer' academic issues in medical sociology.
This analysis of trends and tendencies across the two continents must necess-
arily be highly speculative. M u c h m o r e work needs to be done if these ideas are to be
developed to the level of even a very preliminary hypothesis. Moreover, alternative
explanations immediately come to mind. Medical sociology m a y have had to
develop professional credibility as an academic discipline before it could even begin
to address issues such as those associated with social policy concerns. O n e could
hypothesize that medical sociologists initially attached themselves to a highly
376 Derek G. Gill and Andrew C. Twaddle

prestigious profession, that of medicine, in an effort to develop credibility and

respectability. Only w h e n this was achieved could they begin to develop auton-
omously and to generate questions out of their o w n disciplinary perspective that
were pertinent to broader social issues. Nevertheless, it is interesting to note that in
recent years a critical and reflexive sociology in part based on Marxist or neo-
Marxist principles of analysis is receiving new emphasis in the United States. The
genesis of this movement is perhaps to be found in the agitation and protest
movements that characterized the late 1960s; the emergence of a counter-culture,
the Kent State shootings, the discovery of poverty, the growth of w o m e n ' s liber-
ation and the protest movement against the Vietnamese W a r , the development of
a Black Power movement and agitation for equal rights across the colour divide.
While Theodore Rozack 16 and Charles A . Reich16 can hardly be called sociologists
or Marxists, their work documents the protest movement in general. In medical
sociology similar trends are recognizable in the 1970s in the work of Waitzkin and
W a t e r m a n , " Navarro 18 and Bodenheimer et al.19 to mention just a few prominent
names. The founding of the International Journal of Health Services in 1971 under
the editorship of Vicente Navarro was to provide a forum in which critical reviews
and research on the American health care system were to be published. This
innovation was the logical outcome of the emergence of a critical and reflexive
sociology in the United States and its subsequent application to medical sociology.

Convergence of medical sociology in Europe

and the United States

Today therefore there is a degree of convergence in medical sociology in America

and Europe. A m u c h more critical attitude is emerging towards the health care
professions, partly as a result of the rising costs of health care in all modern Western
industrialized countries. Most countries n o w are making serious efforts, in effect,
to ration health care. O f the countries under review, the United K i n g d o m has
perhaps been most successful in keeping expenditure in terms of Gross National
Product around or under the 5 per cent mark since the inception of the National
Health Service in 1948. The major rationing devices used by the British have been the
mechanism of cues and rigorous control over capital expenditure. The latter has
forced the health care professions in the United K i n g d o m to continue to utilize
hospital buildings, some of which are 100 to 150 years old. In addition, in the area
of elective surgery, waiting lists can often be as long as nine, twelve or even eighteen
months.
Increased concern over rising health care costs has also attracted other
academic disciplines to the general health carefield.Courses in hospital and health
services administration are developing throughout the Western world with a view
to improving health services administration and thereby attempting to reduce
 Medical sociology: What's in a name? 377

escalating cost expenditures. The number of economists interested in health care

has also increased in recent years. Attempts to control expenditures of scarce
resources have also encouraged research to extend our knowledge of the parameters
of health and illness. T h e general consensus in the Western world seems to be the
more services are provided, the m o r e d e m a n d is created for them, and studies of
primary care suggest that as m u c h as two-thirds or as little as one-third of visits to
general practitioners' offices involve psycho-social as well as medical ailments. T h e
question naturally arises whether the treatment of such conditions is an appropriate
role for a medical practitioner. Certainly in the recent past most primary care
physicians have received very little training in the psycho-social disorders and are
therefore not very well equipped to deal with patients whose complaints are of this
nature.
But even more fundamental challenges are facing primary care physicians
today. M o s t studies suggest that about 80 per cent of the illness episodes that
appear in the general practitioner's or family physician's office are either incurable
or self-limiting. In these circumstances the question necessarily arisesare primary
care physicians over-trained? Indeed, have w e built into the medical care system a
component of trained incapacity by broadly training primary care physicians in
secondary and tertiary hospital care settings and then expecting them to deal, for
the majority of their working lives, with illness episodes which are only rarely, if
at all, seen in the hospital sector? In the United States, the high cost of physicians'
services and the lengthy eleven-year training for medical doctors, alongside
increasing pressure from the nursing organizations to increase their professional
competence and the experience of Medical Corps technicians during the Vietnamese
W a r , have in combination led to the emergence of a n e w variety of health care
practitioners, physician extenders. Physicians' assistants, nurse practitioners, medex
personnel and training programmes for emergency medical care technicians have all
expanded in recent years or been instituted. A t present their numbers are relatively
few, but in some areas of the United States, drastically underserved by physicians,
physicians' extenders of various kinds are beginning to take on more responsibility
for providing primary care to the population.
In the United K i n g d o m , more and more primary care physicians work in
group practices or even operate out of community health centres with a rising
number of support staff drawn from the disciplines of nursing and social work.
These support personnel, in the form of district nurses, health visitors and medical
social workers are undertaking increasing responsibility for screening and routine
visits both in the office and in the patient's h o m e . Medical social workers also take
increasing responsibility for dealing with the psycho-social problems that appear
in the doctor's office.
Alongside these changes and initiatives there is m o r e interest in health
education aimed at making people m o r e responsible for their health rather than
placing the major responsibility in the hands of various professional groups. Thus
378 Derek G. Gill and Andrew C. Twaddle

far, it seems fair to say that health education programmes have been relatively
unsuccessful, at least in changing the behaviour of adult groups. T h e inculcation of
good health habits in the school-age population m a y turn out to be the most
valuable target. In any event, the future of primary care practice and organization
is certainly subject to change and reorganization. O n e future scenario m a y be that
primary care physicians become, in effect, consultants to a team of health care
workers in which the latter take the major responsibility for routine health care,
health maintenance, illness prevention and so on, with the doctor acting as the
final court of appeal when illness conditions and problems go beyond the
competence of the other team members.
In m a n y ways the functional autonomy of the medical profession and indeed
of other health care workers is increasingly being limited as the body politic
undertakes more responsibility for the financing of health care. A t present this
tendency is well advanced in the United K i n g d o m where the mechanisms for
making the profession publicly accountable to the broader society have received
continuing and growing attention since 1911. It seems unlikely that these propensities
to reduce the functional autonomy of the medical profession and to increase its
public accountability are likely to decline in the near future.
The increasing complexity and technological sophistication of modern
medical practices has been in part responsible for the development of an interest in
medical ethics in the lastfiveto ten years. Transplant surgery, artificial life support
mechanisms, techniques for the treatment of end-stage renal disease, simple
techniques for inducing abortion, the management of labour so as to control the
time of delivery, create a whole variety of n e w problems centring upon the
doctor/patient relationship. The issues these innovations raise attract the attention
of professional ethicists, sociologists, economists and m a n y others w h o , in the past,
have had little impact upon the doctor/patient relationship. H o w long is it
reasonable to keep somebody alive through the utilization of hyper-alimentation?
In maintenance haemo-dialysis improvements of a technical kind m a y be introduced
which do very little to improve the medical aspects of treatment but considerably
ease the psycho-social burden upon patients and their family for treatment episodes.
W h e r e the innovation is m u c h m o r e costly, but n o more medically effective than a
cheaper but less pleasant alternative, is there any limit to the State's responsibility
to defray the cost? Issues of personal decision-making, distributive justice and the
imbalance of power 2 0 in doctor/patient relationships require m u c h more inves-
tigation and serve again to expand the boundaries of the doctor/patient relationship
beyond the original dyad.
In terms of its place in general sociology, medical sociology has n o w most
certainly c o m e of age. The discipline has m a d e significant contributions to the
development of general sociological theory and has practical and social policy
implications. Medical sociology, through its very nature and interrelationships with
medical practitioners and other academic disciplines, is essentially concerned with
 Medical sociology: What's in a name? 379

the broader problems that the health care industry faces. Medical sociologists have
developed and need to develop even further the ability to work in close co-operation
and collaboration with health economists, health administrators, health educators,
health care professionals and the like. In this way, they must familiarize themselves
with the basic concepts and methodologies of the disciplines with which they have
to interact. Like the general sociologist, the medical sociologist must be unconcerned
about the prospect of further contamination of his discipline. M a n y authorities have
suggested that one of the basic problems of the medical profession is its over-
specialization, leading to problems of communication between the wide variety of
specialties. The social sciences, particularly sociology, would d o well to avoid over-
specialization, thus ensuring that economists, social historians, medical sociologists,
sociologists of religion, of education etc., can still communicate with each other.
A s w e have already seen, the roots of medical sociology lie deep in the
nineteenth century, if not earlier. In the last twenty-five years, the discipline has
grown very considerably but its development has largely been restricted to the
industrialized countries. With rare exceptions, medical sociology has not devoted
m u c h attention to the problems of health care services in the Third World
countries, some of which are intent upon developing a high technology-based form
of Western health care service often largely irrelevant to the health care needs of
their citizens. China, aware that its resources were insufficient to introduce high
technology medicine across the country as a whole, has opted for the development
of a health care system based on hygiene, public health and preventive medicine.
The World Health Organization is placing considerable emphasis upon attempts to
understand the needs, and to contribute to the development of services to meet those
requirements in the Third World countries and actively seeks the collaboration,
co-operation and assistance of medical sociologists in this enterprise. It is to be hoped
that medical sociologists interested in the distinctions between high and low
technology medicine and their application in different national situations will soon
emerge. Again, a degree of convergence is discernible. T h e role of physician
extenders in the developed world with their focus upon the minor but numerically
most frequent ailments and diseases m a y also be the appropriate mechanism with
which to address the health care needs of Third World countries. The role of the
physician extender in the Appalachians or in the Mississippi Delta m a y not be
very dissimilar from that of a similar functionary in the rural areas of Africa and
South America.

Future directions in medical sociological research

While the articles in this issue show that the situation is improving, medical
sociology has fallen short of its potential in the exploration and analysis of health,
sickness and medical care. In fact, it would not be too m u c h to suggest that medical
380 Derek G. Gill and Andrew C. Twaddle

sociology has been co-opted by medical interests in matters of both style and
content. A s N e w argues in his article below, in order to successfully study the
sociology of health, sociology as a discipline must expand its horizons beyond that
of modern Western medicine.

Common assumptions

Sociology has shared a number of assumptions with medicine regarding: (a) accept-
ance of philosophical positivism; (b) a commitment to technological solutions;
(c) a limitation of focus to the European experience; and (d) an assumption that
medicine is beneficial and to some degree 'sacred'. Each of these assumptions needs
to be explored.
The positivist position, that natural events are real and not simply mental
constructs, that there are invariant laws of nature and that nature is subject to the
control of m a n (Bury21 and Parsons22), dominates medicine. Although positivism
has been workable for the physical and biological sciences, it has been problematic
for the behavioural sciences (Yankelovitch and Barrett23). The twentieth century
has seen a struggle for ways to deal with ideas and other 'mental constructs' without
adopting a position that denies any reality beyond the realm of ideas. O n e approach
has been to study ideas as facts in and of themselves, using positivist methods.
These issues are not resolved and will not be resolved here.
O n e important way in which positivist modes of thinking have been manifest
in medical sociology has been in the treatment of 'non-health'. F r o m a
medical/positivist viewpoint, non-health is disease, an objective, measurable state
in which the biological functioning of an organism has been compromised so as to
reduce capacities or shorten life. For the most part, sociologists have accepted this
medical definition. They have assumed the reality of disease and taken as their
task the discovery of the social antecedents of disease or explored the degree to
which subjective definitions are 'reality oriented' (i.e. correspond to medical
definitions). Only recently have the medical definitions been challenged with the
demonstration that the social designation of people as 'sick' is a labelling process
only partly influenced by biological processes (Twaddle 24 and Gill25), the article by
Pflanz and K e u p p below being an example of this approach.
Closely linked with a commitment to positivism is a commitment to techno-
logical solutions. Each time there is a new problem or 'crisis' in medial care (as seen
from the perspective of medical practitioners) the normal solution is to invent or
apply new technology. Hence, the solution to deaths from myocardial infarction is
the creation of cardiac intensive care units and improved emergency transport
systems. Solutions to diagnostic problems are to be found in more sophisticated
laboratory tests.
For the most part, sociologists have not challenged the reliance on techno-
logical solutions, although an examination of the evidence shows little impact of
 Medical sociology: What's in a name? 381

medicine on death rates (although significant impact on causes of death), and n o

improvements in the health of the population attributable to medical technology.
At the same time, reliance on technology has increased the labour-intensiveness of
medical care, driven u p costs and probably increased h u m a n suffering. Cardiac
intensive care units, for example, seem to generate n o better results in terms of
survival than h o m e care for certain heart conditions.28 In the face of this, sociologists
have focused on the process of innovation and the diffusion of technology.
A third shared assumption is that European medicine is the only relevant
type. Western physicians have ignored the theories andfindingsof healers in other
cultures. In the rare instances in which afindingfrom another tradition is thought
to be useful, as in the case of the use of acupuncture for anaesthesia, the explanation
of its effects is rejected. Hence, the interpretation of acupuncture anaesthesia is
reformulated to 'fit' Western theory (e.g. nerve gateways); the Chinese explanation
is rejected without investigation. In fact, healing is accomplished in all cultures and
sociology would benefit from comparative studies.
Finally, and most important, is the shared assumption that medicine is
beneficial and to s o m e degree 'sacred'. M o s t physicians and sociologists share
Carlyle's conception that medicine is the most noble of professions. Its involvement
with life and death issues; the vulnerability of its clients; the chance that relation-
ships m a y become exploitative, all point to a sacred element and a desire to believe
that higher ethical standards are required for the practice of medicine than for other
professions. However, as w e suggested above, the evidence that medicine is
beneficial to society is equivocal; high ethical standards have been assumed, not
demonstrated. In all likelihood, medical practitioners are not significantly different
from others with respect to nobility. Medicine needs to be studied on the same terms
as other occupations.

Medical bias and problem selection

The kinds of problems selected by sociologists for study reflect a medicocentric

view of health care. T w o examples will suffice.
The literature o n health occupations is skewed towards studies of physicians.
There are hundreds of research reports on the medical student and physician that
provide detailed descriptions of the process through which physicians are trained
and h o w they practise. While there are hundreds of articles on nursing, there are
only a handful of studies, the remainder being editorial commentary. Beyond these
the literature is practically non-existent. There arefivestudies of chiropractors (two
dealing with them in relation to physicians), one of osteopathy and none at all
dealing with social work, laboratory technology, inhalation therapy, physical
therapy, occupational therapy or any of the myriad other occupations that have
developed in this century. S o m e studies have dealt in part with social work in
comparison with other occupations, but not with medical social work and its
382 Derek G. Gill and Andrew C. Twaddle

special problems. Worse, sociologists have seemingly accepted medical judgements

about the worth of other occupations. Political terms such as para-medical, allied
health and the like are accepted uncritically by m a n y . A n d occupations other than
medicine are analysed with reference to their relationship to medicine.
Another example is in the literature on the professional-patient relationship.
Here the emphasis has been on investigation of questions thought 'relevant' by
physicians, namely patient compliance with medical 'orders'. The assumption has
been that the success of the relationship and its therapeutic value is a function of
the patient's acceptance of the physician's authority and co-operation with treatment
regimens. There is some evidence that the success of the relationship is a function
of the degree to which the physician complies with patient expectations (Davis and
von der Lippe).27 The effects of physician compliance on treatment success have not
been investigated.
Examples can be multiplied. There are numerous studies of hospitals, but
none of private offices. There are numerous studies of curative services, but
virtually none of preventive and public health services. Like medicine itself, soci-
ology has tended to focus o n those topics that are most peripheral to health.

Failure to provide critical evaluation

For understandable reasonsthe need to gain access to data and the desire to be
accepted as a relevant health-related disciplinemedical sociology has suspended
its critical judgement. T h e capacity of thefieldto provide critical evaluation of
health programmes has been minimized, perhaps because clients would find the
results distasteful. W e can illustrate with three areas where researchfindingsare
suggestive of critical conclusions which, however, have not been drawn: the impact
of medicine on health, the impact of high technology on medical care and the
implications of medical moral entrepreneurship for social control and the concen-
tration of power in society.
W e have already alluded to the problem of assessing the impact of medicine
on health. While there is n o question that medical intervention is beneficial in
individual cases, the effect of medicine on the health of the population is less clear.
The long secular decline in the death rate, resulting in an increase of life expectancy
from 18 years in Bronze-age Greece to over 49 years in the United States in 1900
(Peterson28 and Dublin et a/.29) occurred not only in the absence of medical benefits
but also in the face of dangerous 'heroic' treatments (Twaddle and Hessler).30 While
medicine in the twentieth century has virtually eliminated deaths from acute
infectious disease, these have been offset by an increase in deaths from chronic
disease. While the incidence of acute disease has not changed, it is likely that preva-
lence of chronic disease has increased. The cost of that increase in life expectancy
which can be attributed to medical intervention (1938-55 in the United States) m a y
be increased morbidity in the population. A s has been argued, improvements in
 Medical sociology: What's in a name? 383

health status stem more from improvements in general standards of living and
nutrition rather than medical advances per se. In any event, this is an area in need of
further study along the lines developed by M c K e o w n 3 1 and Powell.32
T o say that Western medicine has become heavily dependent upon high
technology would be an understatement, as would the claim that high technology
is costly. M o r e than anything else, medical technocracy has priced some forms
of medical care out of the range of the average consumer. At the same time, there is
reason to believe that the benefits of this commitment to technology are limited,
perhaps to the point of being superfluous. Investment in super-sophisticated
machinery is relevant, with few exceptions, only to the treatment of rare and exotic
diseases. Such equipment is concentrated in university hospitals, where physicians
and health professionals are trained. The professional, therefore, is taught that rare
and complicated diseases are 'interesting' whereas people with ordinary illnesses are
not. Further, he not only learns to m a k e use of sophisticated machinery in
diagnosing and treating disease, but also becomes increasingly incapable of diagnosis
or treatment in the absence of such technology. A trained capacity with reference to
esoteric technology becomes a trained incapacity with reference to the health needs of
the population. In short, there is need to assess the degree to which high technology
is relevant to health and dependence upon it is making medicine irrelevant to health.
Dependence on high technology in general is problematic for even the most
developed nations. Worse for health at the international level, there is a tendency
to export high technology from developed to developing countries where such an
orientation is, if anything, even more irrelevant to health. The pressures for such
transfer c o m e from two sources. T h e exporting countries have considerable
industrial commitment to the technology, and the export of machinery is in the
interest of their industrial sector. Further, there is an ideological commitment which
leads the developed countries to believe the export of technology to be helpful. O n
the other side is a desire on the part of developing countries to emulate the
developed. They want the symbolic values which high technology carries, the image
of development. Irrelevance to infectious disease problems and environmental
hazards are overlooked on both sides. Needed low technology assistance is ignored.
H u g e investments yield profits for the developed countries without aiding the health
of the developing ones. This, too, is an area in need of research.
For our third example, w e turn to Friedson's33 demonstration of medical
moral entrepreneurship. By this term he meant that medicine has a tendency to
assert its jurisdiction over an ever-expanding range of disorders, including the right
to autonomous performance and control over other occupations with interests in
the same disorders. Elsewhere, this has been referred to as the 'medicalization of
deviance' (Pitt,34 Zola3S and Twaddle 39 ). Virtually everything that is n o w treated by
medicine has at other times been treated by different systems of social control, such
as the church (e.g. leprosy, mental illness) and the secular legal system (e.g. alcohol-
ism, drug addiction). Kittris3' presents compelling evidence that the courts are
 384 Derek G. Gill and Andrew C. Twaddle

attempting to 'divest' the law of jurisdiction over such problems as mental illness,
delinquency, psychopathology, drug addiction, alcoholism, sterilization and the like.
At the same time Zola38 has shown that medicine is increasingly claiming jurisdiction
over these same areas. F e w have noted the importance of this trend and concerned
themselves with its implications. Szasz39 argues that due process and civil rights
developed by the legal system m a y be lost with the transfer of jurisdiction over
mental illness to the medical system. Torrey40 notes the inadequacy of the medical
model for dealing with psychological and social problems and advocates develop-
ment of educational models as replacements.
W h a t seems to be afoot is a major reallocation of power and control in
society. While this should be a matter of deep interest and concern to sociologists,
it has received virtually n o attention.

Notes

1 12
I. Goffman, Asylums, N e w Y o r k , N . Y . , Anchor
Books, 1961.
2
B . Abel-Smith, Value for Money in Health Services,
L o n d o n , Heinemann, 1976.
3
S. Bloom, ' T h e Profession of Medical Sociology in
the Future: Implications for Training Pro-
grams', 1976 (mimeo.).
4
S . B l o o m , ' F r o m Learned Profession to Policy
Science: A Trend Analysis of Sociology in the
Medical Education of the United States',
in M . Sokowlowska, J. H o l o w k a and
A . Ostrowska (eds.), Health, Medicine,
Society, p . 435-47, Dordrecht, Reidel
Publishing C o . , 1976.
6
ibid., p . 437.
6
R . Illsley, 'Promotion to Observer Status', Soc. Sei.
and Med., Vol. 9, N o . 2 , 1955, p . 63-7.
7
R . Strauss, ' T h e Nature and Status of Medical
Sociology', Amer. Soc. Rev., Vol. 22, 1957,
p. 200-4.
8 published in L o n d o n by Routledge & K e g a n
Illsley, o p . cit., p . 66.
9 Paul Ltd.
J. N . Morris, Uses of Epidemiology, Edinburgh,
L o n d o n and N e w Y o r k , Churchill Living-
stone, 1975.
10
M . Pflanz and J. Siegrist, 'Basic Assumptions in
Teaching Medical Sociology in Medical
Schools: T h e Case of Western G e r m a n y ' ,
1976 (mimeo.).
11
E . Chadwick, in M . W . Flinn (ed.), Report to
Her Majesty's Principal Secretary of State for
the Home Department from the Poor Law
Commissioners on an Inquiry into the Sanitary
Conditions of the Labouring Population of
Great Britain, p . 223-6, Edinburgh, Edinburgh
University Press, 1965.
H . J. Geiger, ' A Health Center in Mississippi: A
Case Study in Social Medicine', in L . Cory,
S. E . Saltman and M . F . Epstein (eds.),
Medicine in a Changing Society, St Louis,
C. V. Mosby, 1972.
13
For a concise account of the Aberdeen w o r k see:
R . Illsley, ' T h e Sociological Study of Repro-
duction and Its O u t c o m e ' , in I. A . Richardson
and A . F . Guttmacher (eds.), Childbearing:
Its Social and Psychological Aspects, Balti-
m o r e , M d . , Williams & Wilkins, 1968.
14
For an indication of the extent of Cartwright's
w o r k see: A . Cartwright, L . H o c k e y and
J. L . Anderson, Life Before Death, 1973;
K . Dunnell and A . Cartwright, Medicine
Takers, Prescribers and Hoarders, 1972;
A . Cartwright, Parents and Family Planning
Services, 1970; A . Cartwright, Patients and
Their Doctors, 1967; A . Cartwright, Human
Relations and Hospital Care, 1964. All
16
T . Rozack, The Making of a Counter Culture,
N e w Y o r k , N . Y . , Doubleday, 1969.
16
C . A . Reich, The Greening of America, N e w Y o r k ,
N . Y . , B a n t a m Books, 1971.
17
H . Waitzkin and B . W a t e r m a n , The Exploitation
of Illness in Capitalist Society, Indianapolis,
T h e Bobbs-Merrill C o . Inc., 1974.
18
V . Navarro, ' T h e Underdevelopment of Health of
Working America: Causes, Consequences and
Possible Solutions', Amer. J. Pub. Hlth.,
Vol. 66, N o . 6, 1976, p . 538-47.
19
T . Bodenheimer, S . C u m m i n g s and E . Harding,
'Capitalizing on Illness: T h e Health Insurance
 Medical sociology: What's in a name?
Notes (continued)
Industry', Int. J. Hlth. Servs., Vol. 4, N o . 4,
1974, p. 583-98.
20
D . G . Gill, Limitations upon Choice and Constraints30
over Decision-Making in Doctor!Patient Re-
lationships, Fogarty International Center of
the United States Department of Health,
Education and Welfare, 1977 (in press).
21
J. B . Bury, The Idea of Progress, N e w York, N . Y . ,
Dover Publications Inc., 1955.
22
T . Parsons, The Structure of Social Action, N e w 32
York, N . Y . , The Free Press, 1937.
23
D . Yankelovitch and W . Barrett, Ego and Instinct, 33
N e w York, N . Y . , R a n d o m House Inc., 1970.
24
A . Twaddle, "The Concept of Health Status', Soc.
Sei. & Med., Vol. 8, 1974, p. 29-38.
25
D . G . Gill, 'Cross-National Socio-Medical R e -
search: Summary Statement', in M . Pflanz
and E . Schach (eds.), Cross-National Socio-
Medical Research: Concepts, Methods, Prac-
tice, Stuttgart, Georg Thieme, 1976.
26
H . G . Mather et al., 'Acute Myocardial Infarction: 36
H o m e and Hospital Treatment', B.M.J.,
Vol.3, 1971, p. 334-8.
27
M . Davis and R . von der Lippe, 'Discharge from
Hospital Against Medical Advice: A Study of
Reciprocity in the Doctor-Patient Relation-
ship', Soc. Sei. & Med., Vol. 1, 1967,
p. 336-^4.
28
W . Peterson, Population, N e w York, N . Y . ,
Macmillan Inc., 1969.
29
L . Dublin, A . J. Lotka and M . Spiegelman,
385
Length of Life: A Study of the Life Table,
N e w York, N . Y . , Donald, 1969.
A . C . Twaddle and R . M . Hessler, A Sociology
of Health, St Louis, M o . , C . V . Mosby,
1977.
31
T . M c K e o w n , Medicine in Modern Society: Medi-
cal Planning Based on Evaluation of Medical
Achievement, N e w York, N . Y . , Hofner
Publishing, 1966.
J. Powell, ' O n the Limitations of Modern Medi-
cine', Sei. Med. Man., Vol. 1, 1973, p. 3-18.
E . Friedson, Profession of Medicine, N e w York,
N . Y . , Dodd, M e a d & C o . , 1970.
34
J. Pitts, 'Social Contact', International Encyclo-
pedia of the Social Sciences, N e w York, N . Y . ,
The Free Press, 1968.
36
I. Zola, 'Medicine as a System of Social Contact',
in C . Cox and A . Mead (eds.), A Sociology of
Medical Practice, London, Collier-Macmillan,
1975.
A . Twaddle, ' O n Crime and Illness' (paper pre-
sented at annual meeting of the American
Sociological Association, 1976).
37
N . Kittris, The Right to be Different, Baltimore,
M d . , The Johns Hopkins University Press,
1971.
38
I.Zola, op. cit., 1975.
39
T . Szasz, The Myth of Mental Illness, N e w York,
N . Y . , Harper & R o w , 1961.
40
E . F . Torrey, The Death of Psychiatry, N e w York,
N . Y . , Penguin Books, 1974.
 A sociological perspective
on concepts of disease

Manfred Pflanz and Heinrich Keupp

Disease as coping mechanisms

In all communities disease1 is a phenomenon considered threatening to the indi-
vidual, his group and society as a whole. All societies have therefore developed
coping mechanisms of which medicine and magic are the most important. T h e
experience of disease and death is one of uncertainty and powerlessness in the face
of nature and the supernatural. The inability to predict the onset of ill health and the
doubtful results of m a n y medical interventions are the main sources of uncertainty
in h u m a n life, in order to overcome which every society establishes action systems
specifically designed to relieve not only pain and suffering but also anxiety and
tensions. Surgical, physical and pharmaceutical remedies are only part of these
coping mechanisms. Societies create and maintain a rather specific philosophy of
disease and death which m a y be interpreted as basic and as an important element in
the attempt to deal with uncertainties in h u m a n life, which is w h y elaborate concepts
of disease are part of the philosophy of disease and death. These concepts can be
defined as patterns of ideas concerning the causes, manifestations, definitions and
value implications of events considered, in a given cultural context, to belong to the
realm of disease. Concepts of disease are not only part of coping mechanisms but
relate disease to the social matrix of value systems and thus incorporate the disease
into the social system.
Concepts of disease are everyday social elements and not esoteric expert
ideologies to maintain the value system or exercise power over the ignorant. W h a t is
defined as disease and h o w it is interpreted is part of the notion of h u m a n nature and
generally of cognitive order systems rooted in the mastering and acquisition of
nature (Keupp, 1976, p. 168).

Manfred Pflanz is Professor of Epidemiology and Social Medicine at the Medizinische Hochschule-
Hannover, D 3000 Hannover-Kleefeld, Karl-Wiechert Allee 9 (Federal Republic of Germany). He
has published two books, Social Change and Disease and T h e Social Dimension in Medicine, and
is the International Sociological Association's liaison officer with the World Health Organization
Heinrich Keupp is lecturer in social psychology at the University of Munich and the author
and editor of several books, amongst them The Disease M y t h in Psychopathology and Deviance
and Everyday Routine.

Int. Soc. Sei. J., Vol. X X I X , N o . 3, 1977

 A sociological perspective on concepts of disease 387

Aspects of the concepts

Concepts of disease express views on different issues. In most culturesfivefeatures
can be distinguished: (a) the general delineation of disease as distinct from
other events (including its definition and interpretations); (b) manifestations of
diseasethe organization of signs and symptoms into distinct disease patterns;
(c) general and specific classifications of disease; (d) causes of disease; (e) moral and
other value implications of diseases. Disease is always considered as good or bad,
disruptive or integrative, holy or devilish. Its moral implications are of concern to
the individual as to society: they relate to the causes, manifestations, meaning, and
consequences of disease.
It is only in the past twenty years that sociologists have turned towards
concepts of disease and their origins in modern Western societies. T h e study of
disease concepts in other cultural contexts was the domain of anthropologists w h o
examined it without drawing strict distinctions between psychological and physical
disorders. B r o w n (1976) has pointed out that m a n y sociologists consider inquiries
into disease as rather a 'sociological backwater', and, the social causes, roots and
definitions of disease have therefore been given but scant theoretical interest so that
there are only a few systematic and empirical investigations. Today, probably n o
sociologist would disagree with Fabrega (1974, p. 197): 'Disease is and always has
been a socially created entity.' T h e cultural background of disease is an accepted
fact today, yet the integration of cultural and biophysical views is still very rare.
Fabrega's Disease and Social Behavior ( 1974) attempts such an integration and gives
an assessment of its practical consequences. Sociological work has concentrated
almost exclusively on the phenomenological aspect of disease and on reactions to its
labelling by the social environment or by professional agents. There is almost n o
literature on the social aetiology of diseases at the subjective level, as perceived by
the patient, or at the social level. M o s t sociological work assumes the dominance of
scientific aetiological thinking in modern medicine which is considered to contrast
with lay conceptions. This assumption is true in so far as the 'ideal type' of medicine
is concerned, but it is probably wrong in the everyday routine of patient-physician
encounters. Patients as well as physicians develop various 'layers' of aetiological
conceptions. Both can m o v e from one 'layer' to the other in a dynamic process
of interchange of assumptions about the aetiology of a specific disease. M o s t
sociologists interested in medical matters are clearly in favour of psycho-social
explanations of disease, viewing the purely biophysical approach to aetiology as
dehumanizing and insufficient. Yet both the scientific physician and the social
scientist are part of distinct subcultures in which different concepts of disease exist.
These subcultures are m o r e rigid in their views on causes of disease than the patient
and his physician in an everyday interaction. A t this level there is n o reason for
value judgements such as 'inhuman' or 'inferior'. T h e same is true for the dis-
tinction between a 'medical model' 2 and a 'sociological model' of disease, which
388 Manfred Pflanz and Heinrich Keupp

can coexist as products of historically determined social events. T h e status of the

medical sociologist is not very distant from the social status of the physician. Both
have assumed the functions of the priest in their professional roles, and are less the
real constructors of that social reality called 'disease' than its interpreters. Thus
their interpretations are to be seen as attempts at coping with the uncertainties
surrounding disease and death. However, neither is able to satisfy individual needs
to connect disease with the supernatural, a need which is most urgent in tra-
ditional societies but is still far from negligible in modern society.

Traditional and scientific concepts of disease

Concepts of disease are culture-bound and historically determined: anthropological
studies have shown their variety. There are today n o 'pure' disease concepts uniquely
bound to a specific cultural matrix, as almost everywhere there exist two or three sets
of disease concepts partly side by side, partly closely intermingled. T h efirstset stems
from folk medicine, essentially traditional to all societies. T h e second set takes its
origins from organized traditional medicines: for instance, Ayurvedic medicine in
India; and the third set stems from Western scientific medicine. Fine descriptions are
available of the relationships between disease concepts stemming from all three
sources, as in the highlands of Chiapas where M a y a concepts intermingle Ladino
and Western theories of disease (Fabrega, 1974). Relationships between the two or
three medical approaches drew closer in the post-colonial era, not only at the level
of the individual but also as co-operation developed between their various represen-
tatives. In Western industrialized countries there is still a wide gap between represen-
tatives of scientific medicine and those of folk or lay medicine, but again, at the
level of everyday encounters between patient and physician, there is considerably
less difference. Physicians are less scientific than they are supposed to be, and
patients are quite capable of taking a critical view of lay concepts of disease. Never-
theless, disease concepts in lay and scientific medicine are not identical. Social
scientists assume that the psycho-social dimension of disease is m o r e emphasized in
lay medicine (Keupp, 1976, p. 178), but psychiatrists experience the opposite. There
are very few studies of lay and folk medicine in industrialized countries (Schenda,
1973). Contemporary lay medicine is m a d e u p of various elements. Very little
knowledge is transmitted from traditional folk medicine origins while important
elements are popularizations of professional ideas to suit the language and cognition
sphere of the layman (Keupp, 1976). Other elements are perverted and summarized
from the technological imagination of the last century.
There is a lively exchange between lay and scientific medicine in regard to
disease concepts. Claudine Herzlich (1973, p. v) says:
As these medical definitions increase in importance, mainly because they contribute so
much to the structuring of laymen's ideas about illness, they tend to lose their
 A sociological perspective on concepts of disease 389

unquestioned acceptance as sources of incontrovertible evidence Lay conceptions and

'biases' are amongst the factors which to some extent influence medical thought and
practice.
This can be observed in the Federal Republic of G e r m a n y where a considerable
percentage of medical practice is part-time or full-time 'outsider' or marginal medi-
cine such as chiropractic, acupuncture, focal diagnostic, homoeopathy or Kneipp
therapy. M o r e than in all varieties of academic medicine, lay medicine views disease
as a specific social way of life. Interpretative processes lead to actions which seem
to fit this. For laymen as well as for experts the pattern of definitions and interpret-
ations is drawn from the same socio-cultural source (Keupp, 1976, p. 178), but this
mainly concerns the social context of disease and applies less to the cognition of the
processes of nature and their laws. There is a stepwise increase in the sophistication
of knowledge and the mastering of nature in a process of the division of labour. This
happens in medical matters in the same w a y as in science or technology. T h e first
encounters between traditional concepts of diseases and Western scientific medicine
in non-Western cultures showed that there was almost n o c o m m o n ground. But
even if Western medicine is initially rejected by representatives of traditional medi-
cine the latter slowly adopt elements thereof. In some cases people even seem to
distinguish between domestic 'folk' and Western diseases. T h e more physicians and
health workers in non-Western cultures are trained according to the principles of
Western medicine, the more concepts m a y converge, though traditional concepts,
purely Western concepts and a mixture of the two m a y continue to exist side by side.
In industrialized societies there is indeed a gap between traditional or folk medicine
and scientific medicine. But the population shares its history, fundamental habits
and world view with the physicians. Both originate from the same social matrix.
Both are not only witnesses to technological progress but its masters. It is not
exceptional for a working-class patient to be more involved in the process of mas-
tering nature by technological means than his doctor. Yet because of the general
division of labour they d o not necessarily speak the same language in respect to
medical matters. While it is therefore too simple to assume that there are two
worlds, one of the layman and the other of the physician, a stepwise increase in the
sophistication of knowledge does occur. Disease concepts and diagnostic terms are
used in quite similar ways by the general practitioner and the layman. T h e gap is
larger between the general practitioner and the hospital specialist(L. v. Ferber, 1971),
w h o , however, m a y be unable to understand the concepts and terms of the 'elite' of
his o w n specialism.

Subjective and objective concepts of disease

It is generally assumed that modern medicine adopts an approach based o n the
reification of disease; that is to say, the patient is considered to be afflicted by an
390 Manfred Pflanz and Heinrich Keupp

illness which is something objective, an ontological entity. Subjective perceptions,

emotional reactions or social factors are regarded as concomitant symptoms but not
as essentials. This is not unique: in non-Western cultures also m a n y people think of
disease as independent of them, to be withdrawn by suction, or removed by surgery,
and which can be transmitted to others. The opposite view holds that the onset of a
disease is necessarily a social event which shapes a new identity and new roles.
Neither the objective nor the subjective concepts of disease define w h o is diseased or
what is the category to which disease belongs. In Western culture the linking of the
subjective and objective concepts to the individual is out of the question. However,
disease can also be understood as pertaining to the supernatural and only manifested
in m a n , while another modern view considers disease as symptomatic of a whole
society or group. Finally, some psychiatrists and sociologists throw open to dis-
cussion whether families can be the real unit for diseases (Mauksch, 1974), since
m a n y observations have shown that the bearer of a symptom, the sufferer and the
'truly diseased' within a family m a y be different persons. In such cases it m a y be
claimed that the whole family is diseased.

Delineations and definitions of disease

Societies possess m o r e or less clear ideas on what constitutes a disease in distinction

from other phenomena, such as delinquency, sinful behaviour, bad luck, bad habits,
fate (e.g. congenital malformations), etc. Like every concept of disease such distinc-
tions are also based upon accepted ideas concerning nature and the supernatural,
upon experience and knowledge, language and other symbols. They are connected
with attitudes on right and wrong and thus have moral implications, being trans-
mitted from parents to children in the course of socialization processes.
The distinction of various phenomena also depends o n the existence of
institutions and action systems to deal with a given 'problem'. It is possible for
institutions to be created as coping mechanisms for existing problems but socio-
logical analysis can show that m a n y problems are actually created by institutions
originally established for dealing with quite different problems. Another approach
to disease definition can be called the statistical dimension, whereby very prevalent
manifestations are not considered as diseases but as normal. In m a n y African
cultures, umbilical hernia in young children is so c o m m o n that it is not considered
to be a disorder.
Western medicine uses the statistical concept of disease only in selected areas
and prefers the normative concept in combination with the statistical one.
This normative-statistical dimension is an important aspect of disease
concepts in both the lay and the professional spheres. S o m e diseases occur suddenly
at an imperative level of severity, imperative because the patient and his family or
group members perceive an urgent need for immediate action. In such cases there is
 A sociological perspective on concepts of disease 391

a rather steep gradient of severity while in other cases this gradient is so smooth
that there is n o clear dividing point to distinguish disease from 'normality'. Yet an
important part of a social concept of disease is where to draw the demarcation line
between 'healthy' and 'sick'. This line is drawn according to implicit standards which
take account of sex and age. It is this demarcation line which separates 'disease'
from 'non-disease' rather than 'feeling ill' or not: disease is always an organized
pattern of signs and symptoms requiring action.
The delineation of disease along a continuous distribution curve according to
the number and severity of signs and symptoms is similar to the arbitrary lines drawn
by medicine in the definitions of hypertension, diabetes, anaemia, obesity or neurotic
disorders, to take but a few examples.
In modern societies, concepts of disease are changing quite fast along the
dimensions described. The results are far from trivial and not of merely theoretical
interest. There are severe impacts o n the structure and costs of health systems, a
dramatic shift of social control to medicine, and changes in the moral implications
imputed to certain events and conditions. Furthermore, changes in disease concepts
m a y have both stabilizing and disruptive social consequences. The stabilizing effect
m a y be the result of redefining social conflicts as medical problems and thereby
neutralizing the conflict. The disruptive consequences m a y be manifold: hiding
instead of solving social conflicts; powerful influences on conditions at work, on
families and legislation or deleterious impacts on economic growth. There is a strong
tendency to subsume more and m o r e under the broad social category of'disease'.
Alcoholism is n o longer a bad habit but a disease, as is overnutrition leading
to obesity. Delinquency is more and more defined as a psychiatric condition which
needs treatment and not punishment. Afidgettoday is a child with a 'hyperkinetic
syndrome'. Small breasts, baldness and being too tall or too short are considered
disorders requiring expensive medical treatment; all these were formerly just
personal attributes shaping individual social identities.
O f equal importance is the broadening of disease concepts along the
normative-statistical dimension. T h e demarcation line between 'healthy' and
'diseased' is shifting towards the lower end of the scale, towards degrees of minor
severity. This can be observed in popular disease concepts as well as in the pro-
fessional ones. There is more tolerance towards the diseased person, there are more
benefits to be derived from disease, and the status of the diseased is mounting. T h e
medical profession 'plays safe' and uses the decision rule broadly dealt with by
Scheff (1963) and Freidson (1970, p. 255 et seq.): w h e n in doubt it is wiser to diagnose
illness than not. Resetting the dividing line between disease and non-disease towards
the lower end of the scale is an expression of this decision rule. Freidson (1970,
p. 258) gives three explanations of w h y physicians tend to 'overdiagnose':

It would be plausible to predict that 'overdiagnosing' and 'overprescribing' are most likely
to be found in conditions (a) where the physician is most likely to gain some benefit from it;
392 Manfred Pflanz and Heinrich Keupp

(b) where the patient is in distress but the signs and symptoms are ambiguous; and
(c) where some conventional and popular diagnosis and treatment are available which are
not absolutely contradicted by what signs and symptoms there are.
T h e first explanation is unsatisfactory in cross-cultural perspective because the
tendency to broaden disease concepts is the s a m e in countries where the physician
does not directly benefit from overdiagnosing, as he m a y under entrepreneurial
medicine. T h e second reason must be supplemented b y the observation that over-
diagnosis occurs increasingly even w h e n the patient is not in distress a n d does
not experience signs a n d s y m p t o m s . T h e rapid expansion of medical screening
contributes to the inclusion of factors into concepts of disease which were formerly
not recognized at all, for instance the presence ofriskfactors.
There are major trends in m o d e r n society which promote such extensions of
disease concepts. W e have mentioned influences emanating from lay culture, a n d
those strong ones originating from clinical thinking and medical power, but the list
would be incomplete without mention of the influences of health-care systems in the
m o d e r n social State.3 C h . v. Ferber (1975) has pointed out that concepts of disease
are extended and m o u l d e d by health-insurance acts and other State regulations of a n
imperative character. There is a strong connection between the benefits provided by
health insurance or a national health system and concepts of disease. T h e removal of
economic barriers between patient a n d physician, compensation for economic
losses due to sick leave and the feeling (on the part both of the physician and the
patient) that health insurance 'pays for everything' have contributed to the expansion
of disease concepts. Apparently the interests of society, the individual a n d the
medical profession have m o v e d in the s a m e direction. Y e t liberalization is not
unbounded: the regulations of social health insurance and the organization of the
health-care system ensure that arbitrariness of interpretation and definition are
limited by institutionalization (Keupp, 1976, p . 178-9).

Organization of signs and symptoms

into disease patterns
T h e patient perceiving certain signs and s y m p t o m s m a y wish to order these into a
disease pattern before he defines himself as ill. In cultures in which simple schemes
provide a framework for disease patterns the patient m a y seize u p o n a correct
interpretation. H e has learned what s y m p t o m s constitute a 'hot' or a 'cold' disease.
In cultures dominated by Western scientific medicine ideas about the configuration
of signs and s y m p t o m s are almost exclusively derived from professional medicine:
laymen have n o a u t o n o m o u s concepts of the relationship of signs and s y m p t o m s to
disease. It has repeatedly been s h o w n that the average person experiences o n a n
average day a certain n u m b e r of signs a n d s y m p t o m s . According to K o s a a n d
Robertson (1975, p. 58)
 A sociological perspective on concepts of disease 393

what a 'layman' perceives is a comparative difference between the present (acute)

functioning of health and its previous or usual functioning. The felt difference is communi-
cated in the relative terms of symptoms which furnish rather imperfect clues to the total
disturbance and (with a few exceptions such as fever) cannot be quantified by the layman.
Given the broad range and limited quantification of disturbances, the layman tends to use
subjective criteria in judging whether an observed phenomenon should be assessed as a
symptom, and these criteria vary according to the circumstances.

There has to be a postulate, a perceptual threshold which determines whether a

disturbance is to be assessed as a s y m p t o m . There is plenty of evidence that this
threshold depends on personality, situation and relationship to significant others.
But from a sociological point of view it is important to assess whether socially
determined concepts of disease exist which provide criteria to determine whether
incidental symptoms belong to a disease or not. There are n o empirical data to
answer that question but it can be postulated that medical concepts are so pervasive
in Western societies that the interpretation of a symptom or sign is determined by
direct experience with medicine or by exchange with experienced persons.
Language and other expressive symbols are very influential in this respect
(Fabrega, 1974; K e u p p , 1976), there being a close relationship between available
terms and perception. Medical terminology familiar to the layman determines h o w
he views bodily functions and their disturbances. In an encounter with a physician
only such symptoms can be communicated as can be n a m e d by the patient.
Sociologists deplore that physicians use a medical vocabulary which is not compie-
hensible to the patient (L. v. Ferber, 1971; Field, 1976). However, physicianspar-
ticularly family doctorsare capable of using terminology which is comprehensible
to patients and in this respect are their main teachers. Patient and physician meet
on c o m m o n ground of uncertainty which can best be overcome by using a n a m e
for the disease. This serves its purpose only if both patient and physician use a
similarly construed language, even if some terms are different.
The organization of signs and symptoms into disease patterns occurs during
and owing to the interaction between patient and physician. Sociologists have
devoted considerable efforts to a theory of disease as deviance which is structured
into patterns and forms fresh social identities; this, however, is beyond the scope of
this article (Freidson, 1970; K e u p p , 1976).

Classifications of disease

Popular and professional concepts of disease employ a taxonomy which distinguishes

a m o n g various classes of disease. There are m a n y taxonomies in non-Western
cultures (see Fabrega, 1974) that employ a gross grid in which single diseases can
be located, such as hot-cold, natural-unnatural. Furthermore, m a n y cultures have
more specific ideas about certain diseases with defined symptoms. In principle the
394 Manfred Pflanz and Heinrich Keupp

same is true in Western culture: both layman and physician use gross grid classes,
mostly a mixture of aetiological, evaluative and phenomenological elements. M o s t
important is the gross classification into 'somatic' (or physical) and 'nervous' (or
psychological) diseases. The further one moves from the lay into the sophisticated
medical sphere the more groups and names of diseases appear. A s already m e n -
tioned, there are classifications used by patients and primary physicians containing
similar conceptual elements, while at the other extreme there are those used by the
specialist w h o needs more and more discrete terms. L . v. Ferber (1971) has shown
that the general practitioner uses (in line with his patient) about twenty different
names for a nervous breakdown* whereas the International Classification of Diseases
contains but a single term and a single number. B y way of contrast, where patient
and general practitioner use the term 'diabetes' the International Classification of
Diseases contains m a n y terms for various subcategories. N a m i n g a disease reduces
uncertainty and provides support to the patient particularly if the n a m efitsa lay
taxonomy as part of a disease concept. It cannot be said that medical practitioners
agree on a single scheme or taxonomy. N o taxonomy is considered as fully satisfying,
and recent moves are in the direction of abandoning such classifications, and
adopting instead classifications of problems. If this spreads into medical education
and practice there is a chance that patients and physicians will communicate m u c h
better, but it is open to question whether this artificial taxonomy will be adopted as
part of the popular and professional concepts of disease.

Aetiological concepts

Concepts of disease almost always include some idea about causes. In any cultural
sphere more or less elaborate aetiological theories are developed which match
notions about cause and effect in general. In societies in which supernatural powers
are held responsible for rain and drought the same powers are held responsible for
disease. In a society in which a mechanical world view prevails the causes of disease
are generally equally thought to be of a mechanical nature. However, there are m a n y
exceptions. India runs atomic power plants but a large proportion of the population
believes that astrological constellations determine the fate of m a n and the course
of diseases. At the same time m a n y Indians believe that inappropriate consumption
of 'cold' or 'hot' food (in the Hindu sense) causes a great range of diseases.
In modern societies aetiologic concepts are diverse. Mechanical concepts
prevail in both the lay and the medical spheres, but patients and physicians are
convinced that psychological factors m a y play a role ('stress') in disease aetiology.
I d o not agree with those w h o believe that most patients accept psychological
aetiologies whereas most physicians reject them. However, there are some
remarkable disagreements concerning causes of disease as between patient and
physician. In modern society also m a n y patients believe firmly in the role of fate,
 A sociological perspective on concepts of disease 395

sorcery, mysterious ionizing rays and magnetic power in disease aetiology, whereas
physicians uniformly reject these. Other potential causes are perceived by the
layman and the physician in different ways: overconsumption of calories, saturated
fatty acids or salt are regarded by physicians as causes of certain chronic diseases,
while the layman rather accuses'bad food' for his troubles. For infectious diseases
the layman considers that cold is m o r e important than germs; the physician holds
the opposite view.
T h e aetiologic concept is part of the coping mechanism of the layman w h o
needs to believe in a certain cause. Medicine often leaves him frustrated in this
respect because there are m a n y diseases of which the causes are not k n o w n or in
dispute. For the doctor uncertainty is less because, for most diseases, treatment is
independent of knowledge about causes

Moral and general value implications

of disease concepts

Concepts of disease are not value-free, since disease is woven into the fabric of moral
and social values. Because disease m a y be disruptive of the group it m a y be evaluated
as sinful, as immoral, or as deviance from group norms. Therefore, the sick are
sometimes punished. T o impute a moral value to disease and to the sick has the
latent function of discouraging group members from falling ill. However, this is a
rather hypothetical interpretation. Like other major events of social life, disease is
evaluated in terms of the goals of society. There are m a n y ways of dealing with
disease to counteract its disruptive effect: it can be ostracized, it can be neutralized,
it can become a positive or useful element. That scientific medicine is value free is
considered a great modern advance. H e w h o is certified as diseased is exempt from
responsibility. Yet all this lies in the imagination of scientific medicine. In fact both
practical and lay medicine belong to the moral institutions of society. Patients and
physicians are quite ambivalent in regard to the moral values of disease, as is shown
in articles in professional journals and in the media of mass communication. W e are
told that m a n y patients are responsible for their diseases because they smoke,
overeat or drink alcohol, that they use disease for secondary benefits and that they
must be educated to behave in ways appropriate to the medical point of view.
Powers of social control are thus invoked with the result that the physician perhaps
acts as more of a 'moral entrepreneur' (Freidson, 1970) today more than in the past.
O n e derives the impression that sociological literature o n deviance, labelling and
social control does not open the w a y towards concepts of disease free of moral
values. It would seem rather that certain sociologists wish to replace the physician as
moral entrepreneurs and agents of social control; which alerts us to regarding the
medical sociologist not as a detached observer of events in medicine but as a figure
assuming a n e w function within the changing context of disease.
 396
Notes
1 2
In this article the terms disease and illness will
be used synonymously. M a n y sociological
writers and many dictionaries do not dis-
tinguish between them. S o m e sociologists
distinguish disease from illness on the basis
of objectivity and subjectivity. D . Field (1976)
makes this very clear: ' "Disease"... refers to
a medical conception of pathological abnor-
mality which is indicated by a set of signs and
symptoms. "Illness" on the other hand refers
primarily to a person's subjective experience
of "ill health" and is indicated by the per-
son's feeling of pain, discomfort, and the
like' (p. 334). There is no such distinction in
certain other languages. In German, for
instance, psychosomatically minded phys-
icians and sociologists influenced by existen-
tialism sometimes distinguish between disease
(Krank-heit) and being ill (Kranksein).
Being ill involves the entire person and not
only the subjective experience of ill health.
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F E R B E R , C h . v. 1975. Soziologie fr Mediziner.
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Manfred Pflanz and Heinrich Keupp
The term 'medical model' has never been explicitly
defined. Sociologists understand it as a w a y
of classifying disease exclusively as deter-
mined by structural or functional changes in
the body. In medicine the term is not in use.
Modern medicine is not based upon a single
theory of disease but is rather an open theor-
etical system strongly influenced by pragma-
tism. Thus, another property of the 'medical
model' is the claim that something (not only
a disease) belongs to the domain of medicine
and has to be handled according to the rules
of the medical action system.
3
W e prefer the term 'social State' to 'welfare State'
because today social politics go far beyond
welfare politics which have a rather deroga-
tory ring.
4
O f course, any individual physician uses only a
few of these terms, and does not assign each
term to a distinct disease with specific symp-
tom configurations.
Psychological Analysis. London and N e w
York, N . Y . xvi+159 p.
K E U P P , H . 1976. Abweichung und Alltagsroutine. Die
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H a m b u r g , Hoffmann u. C a m p e . 239 p.
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Harvard University Press, x + 4 5 6 p.
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 Monitoring and servicing
national health
Health service delivery
in developing countries*

Amor Benyoussef

Introduction

The purpose of this article is to review recent work dealing generally with method-
ological and technical issues in health and development. It also presents examples of
the use of the social sciences, including health demography and economics, and their
application to the question of health services delivery. Itfinallyanalyses some
countries' experiences in Africa, Asia and Latin America in dealing with the delivery
of health services to the underserved rural and nomadic populations. In this
connection the author's views are offered o n the methodology andfindingsof
some W H O country-assisted programmes in the area of health services delivery.
The overwhelming magnitude of unmet health needs in m a n y countries
throughout the developing world underlines the evidence of inability of 'scientific
medicine', as it is n o w k n o w n , to meet the needs of non-industrial underprivileged
populations. In fact, this should not be directly related to the failure of scientific
medicine as such, but to the adoption of health-care delivery systems unable to meet
the needs and possibilities of non-industrial populations. These failures, combined
with the apparent success of a completely different approach to health care currently
witnessed in some isolated regions of the world, has led to the concept of healthcare
community-based or 'primary' health care.
Health care is one of the most important of all h u m a n endeavours to improve
the quality of life and yet a large proportion of the world's population has n o access
to health care at all, and for m a n y of the rest the care they receive does not alleviate
their problems. 1 The spectacular advances of medical science have not touched the
majority of the people in the world. T h e majority of the developing world's popu-
lation still suffer and die from the same diseases which afflicted their forefathers.

Dr Amor Benyoussef, a Tunisian citizen, is a medical economist and demographer at present serving
in the Division of Strengthening of Health Services of the World Health Organization, 1211 Geneva 27
(Switzerland). He has been adviser to several national and international institutions and visiting
professor at universities in the Americas, Africa and Europe. He has published two books and many
articles and recently contributed substantially to health programmes for rural and nomadic popu-
lations in the Sudan.
* The author alone is responsible for views expressed
in this article.

Int. Soc. Set. J., Vol. X X I X , N o . 3, 1977

398 Amor Benyoussef

There is a rising clamour to provide medical care to all the people in a country and
simultaneously a growing awareness that the biomedical sciences by themselves
cannot solve the problem of h o w best to deliver the scarce health care resources to
large numbers of people.
Other methodologies for analysing and managing complex social systems are
essential if w e are to m a k e even a beginning in providing medical care to all the
population. Stallones2 expressed this opinion w h e n he wrote that:

medical care has little, if any, effect on the health of a community [because] from a
community health viewpoint medical care always comes too late. The major benefits that
have accrued to us in the past hundred years have resulted from the operation of non-
specific influences not under our [i.e. medical profession] direction while scientific advances
have been based very solidly on Aristotelian logic and reductionist philosophy. O u r
obsession with reductionism has led us to ignore the very real values of a systems-oriented
approach. Three notionsthat an effect has a complex web of antecedents; that a cause
produces an intricate ramification of effects; and that modification of one element of a
system m a y be transmitted into distant responsesopen the door to a genuinely eco-
logically oriented approach to the prevention disease.

It is impossible to plan for health care without considering the circular caus-
ation at work between the healthfieldand the whole social environment. Myrdal 3
cautions against oversimplifying our understanding of health by isolating it from
other socio-economic, institutional and policy factors of the development process.
However, it has long been held true that medical care cannot be considered
merely in terms of costs incurred and material benefits accrued, but also must be
justified on the basis of relief of pain and suffering. A s Candau* points out:

It is amazing to see h o w great a part of their resources poor people are willing to use, and
do in fact use, in order to alleviate the suffering caused by ill health, though of course their
sacrifices may be ineffective.

In order to relate these viewpoints an intersectoral modelling of health and the socio-
economic environment in developing countries has been developed which attempts
to relate environmental factors to fertility and mortality rates and which simul-
taneously investigates the m a x i m u m feasible expansion of health services. A t a
macro-level this effort relates the health sector to other sectors relevant to socio-
economic factors and their interactions and stimulates the dynamic behaviour of
the overall system; at a micro-level it examines the expansion of health services.6
 Health service delivery in developing countries 399

Population coverage and use of health services

General framework

W e k n o w , of course, that providing health services is m u c h more problematic in

developing than in developed countries. Resources are in short supply. Ratios of
the numbers of doctors, nurses and other professionals to the population m a y be of
the order of 10 to 100 times smaller than those pertaining in the m o r e affluent
societies. The availability of hospitals and of modern medical technology is perhaps
even less equitably distributed a m o n g the nations of the world. Even within devel-
oped countries, moreover, the distribution of medical care facilities is highly
skewed. However, the tendency for both technological and manpower resources to
mainly concentrate themselves in urban centres, and particularly in the primate
cities of the developing countries, is even more pronounced. The result is that while
in the urban areas of m a n y developing countries substantial facilities m a y exist,
rural areas m a y frequently have almost a complete dearth of manpower, facilities
and modern technological resources for medical care.
Moreover, facilities are frequently inadequately staffed, maintained and
supplied. It is not u n c o m m o n , especially at the periphery, to find hospitals
or dispensaries without even minimally adequate supplies or standing idle
because there is n o one to offer care. Problems of organization and adminis-
tration combine with difficulties in transportation to aggravate this situation of
acute scarcity.
A t the same time, a m o n g the rural populations which constitute the majority
of the peoples of most developing countries, modern medicine is usually seen as no
more than an ambiguous good. T h e theories and practices of Western medicine
often clash violently with the accepted maxims and values of traditional society.
Frequently, both the canons of folk practice and the existence of native practitioners
seem to satisfy most of the medical needs of most of the people most of the time.
W h e n modern Western medicine, whether under governmental or private spon-
sorship, comes to the hinterland of developing countries it usually comes both as a
strange and perhaps fearful innovation and as a competitor of established ways of
obtaining help for the sick.
O n the other hand, the need for medical care is very high a m o n g the popu-
lations of developing countries, characterized as they are by high degrees of poverty,
unchecked exposure to communicable diseases, and low life expectancy. These needs
are particularly great a m o n g infants and young children, but it is probably fair to
say that the level of need of populations in the typical developing countries is
substantially greater than for those of the more affluent societies where medical
services are more available.
W e m a y summarize the foregoing considerations by making three general-
izations which, broadly speaking, apply in most developing countries of the world:
400 Amor Benyoussef

Even within developed countries, the distribution of medical care facilities is highly
skewed. However, in the developing countries, the tendency for both techno-
logical and m a n p o w e r resources to concentrate in urban centres, and par-
ticularly in the primate cities, is even more pronounced.
Facilities which d o exist are frequently inadequately staffed, maintained and
supplied. It is not u n c o m m o n , especially at the periphery, to find hospitals or
dispensaries without even minimal supplies or standing idle because there
is no staff to offer care.
Problems of organization and administration combine with transportation diffi-
culties and further aggravate the situation.
These generalizations seem not to hold w h e n 'Western medicine' is understood,
accepted and the need for it felt by the people concerned.
There are two types of explanations regarding utilization of health services in
developing countries. They concern respectively (a) health facilities; and (b) popu-
lation characteristics. Health services utilization rates depend u p o n a complex
set of factors relating to the interaction between individuals w h o perceive a
need for service and the specific practitioners or facilities which are available
to them.

Health facilities. It is generally assumed that the greater the expertise and sophis-
tication, the m o r e effective the results of modern medical care. This is still highly
controversial but has led, especially in developed countries, to an increasing
tendency towards specialization on the part of physicians and other health workers
and towards concentration of services in hospitals and other complex facilities where
multiple and complex technologies are available for the treatment of the ill. In
developed countries, there is evidence that the utilizing public is increasingly taking
advantage of the m o r e sophisticated facilities both in terms of the focus of care which
they select and of the type of practitioner which they visit.

Population characteristics. A s the population becomes knowledgeable about dif-

ferent levels of sophistication of medical services, it is reasonable to m a k e two
hypotheses about the utilization of services in the various types of medical facilities:
(a) populations will tend differentially to choose the facility providing the most
sophisticated of services; and (b) the productivity rate (i.e. the number of cases seen
per professional worker, or other similar measure), will be greater in facilities
possessing a large range of services and technical sophistication than in those pro-
viding fewer services. S o m e medical-care planners, believing that these hypotheses
will be borne out by the evidence, have argued that the whole notion of providing
unsophisticated 'minimal' service centres to remote rural populations needs to be
reconsidered.
Demographic and social factors which differentially affect the coverage and
utilization of health services in developed countries probably operate in developing
 Health service delivery in developing countries 401

regions but often with increased force. Studies on utilization of health services in the
developed countries have repeatedly suggested that the rates of utilization vary,
according to such parameters as socio-economic status, education, urban/rural
differences and according to a n u m b e r of culturally determined attitudes. So-called
'predisposing' or 'enabling' factors have been clarified and defined for thefirsttime
in a recent international study on health care.'
It has been k n o w n for m a n y years that socio-economic status is associated
with differences in the degree of utilization of physicians and other health services
in industrialized countries. The different utilization rates reflect both the economic
barriers to service and the differential demands a m o n g population subgroups for
such services. Poverty appears to inhibit the use of health services in at least one
way. These effects are likely to be m o r e marked in developing than in developed
countries because of the greater relative differences in affluence and because of the
scarcity of health resources.
Health care is a commodity: w h e n health insurance is unavailable, economic,
social, cultural and logistic barriers are obviously of tremendous importance. In
developing countries, the reality of the economic barriers associated with poverty
are greatly magnified, and even minimal charges m a y m a k e the use of health care
prohibitive for poor families. In m a n y developing countries medical services are
offered free by the government, but for the very poor, the problem of obtaining
medical care m a y often conflict with the need to work in order to support a family.
Besides, the distance the rural poor would have to travel constitutes a constraining
factor. O n balance, economic barriers as such are probably less of a hindrance to
obtaining medical care in developing countries than they have historically been in
'free enterprise' countries.
Plato's observation that there are two kinds of medicine, one for the rich and
one for the poor, is true for most of the world. W h e r e medicine is controlled by the
mechanisms of the market, these differences are reflected in a differential quality of
the care available. W h e r e economic barriers are removed through charity or the
provision of public medical care, the wealthy often feel, correctly or not, that they
can purchase better care and associated amenities through private medical practice.
Public or charity clinics often have social characteristics which deter m a n y of the
poor from making full use of their facilities. T h e bureaucracy, impersonality,
unpleasant facilities and long waiting time which often characterize hospital
outpatient departments are also deterrents to use of medical care. W h e n ethnic and
other cultural differences are involved, the social distance between providers of care
and recipients is sometimes so marked that medical encounters become aversive to
those in need. It is generally believed that demographic, economic, social, cultural
and logistical barriers also operate with a high degree of force upon the populations
of developing countries. In m a n y , mere distance is a major predictor of w h o will use
health services. Physicians and other health workers in developing countries
usually represent the advantaged, if not the lite, classes of society; by virtue of their
402 Amor Benyoussef

education and training they m a y find it difficult to communicate with uneducated

groups.
Attitudinal factors seem to also play a major role. A m o n g the psychological
manifestations of poverty are a number of attitudes which inhibit the utilization of
medical care, including a lack of sophistication and understanding about need for
care and a similar lack of appreciation of modern medicine. Above all, the poor, no
strangers to problems of all sorts, m a y c o m e to have a higher threshold for the vicis-
situdes of health; apathy comes to be a presiding symptom of poverty. The greater
the degree of poverty the more pronounced are its psychological concomitants.
Finally, urban/rural status and 'modernizing' characteristics constitute still
another set of factors. In developed countries, use of medical services tends to be
higher for urban residents than for those in rural areas. Apparently, the d e m a n d for
medical care in relation to need a m o n g rural dwellers is often lower than it is a m o n g
urban people.7 This m a y reflect the results of poverty (so often a rural phenomenon),
educational differences, or differential perceptions of the adequacy of available
medical care facilities. In developed countries differences between rural and urban
areas have become less marked over the lastfiftyyears. In most developing countries,
however, these differences are still pronounced.

The Tunisia studymethodology and findings

A review of the present state of knowledge of the factors involved in the utilization of
health services shows that few studies are concerned with developing countries and
rural areas of developed countries; that there is little multidisciplinary research;
and, above all, that few studies are action-oriented. This complex question, which is a
cause of concern for the health authorities and a subject of controversy a m o n g
research workers, needs to be clarified. In the study of the interaction of health
services and their users a multi-disciplinary approach permits the identification of
medical, demographic, ecological and socio-economic determinants as well as
organization and management factors. Analysis of the adequacy of health services
requires statistical analysis of both supply and demand in terms of cost and consumer
satisfaction. This is an essential element in the planning, management and evaluation
of health services.
The Tunisian study,8 carried out with W H O assistance between 1969 and 1972,
emphasized that both the factors having to do with the distribution and type of
facilities in various regions of developing countries and the demographic and socio-
economic factors characterizing their populations interact to determine actual levels
of utilization of health services. The investigators worked out a technically simple
and reasonably inexpensive methodology. This requires population sample surveys,
the investigation of health services, and methods of analysis aimed at developing
statistical indices. These methods were applied in a study carried out in the
Governorate of Nabeul, Tunisia, by the Tunisian Ministry of Public Health and
 Health service delivery in developing countries 403

W H O . In each of seven zones (three urban and four rural) a sample of the population
was selected for study on the basis of a household survey and analysis of medical
records.
The household survey was used to ascertain which factors in a given p o p u -
lation discriminate high and low levels of utilization. In all, 678 (446 urban and
232 rural) households, comprising 3,808 individuals, were interviewed. The estimated
utilization rates, based onfiveyears' use of the health services by persons whose
medical records could be retrieved (38.5 per cent of the total sample), differed
appreciably between the urban (88.5 per cent) and rural (46.2 per cent) zones,
although the numbers of visits per illness were practically identical. T h e estimated
utilization rates for the entire study population were appreciably lower (49.7 per cent
and 19.8 per cent). A n analysis of the eighty-six diagnoses found revealed that
30 per cent of the medical and social workload of the health services studied fell into
four categories: acute bronchitis (10.6 per cent in urban zones and 13.9 per cent in
rural zones); influenza (5.9 per cent and 3.4 per cent respectively); diarrhoea
(7.7 per cent and 9.5 per cent); and vaccinations or inoculations (7 per cent and
3.2 per cent). Three categories accounted for almost half of the conditions treated
by the health services: diseases of the respiratory system, major gastro-intestinal
disorders, and skin diseases. There was little difference in the diagnostic pattern
between urban and rural zones.
The questionnaire used in the survey covered demographic and socio-
economic patterns of respondents, their perception of the need for care and advice,
their experience of the health services (including their attitudes towards them and
their staff), and self treatment and recourse to traditional medicine. Users were
initially grouped into four categories in order to identify the relation between the
extent to which they used the services and their attitudes and socio-economic
characteristics. For the analysis, only two categories were taken into consideration:
households making extensive use of the servicesi.e. those 90 per cent or more of
whose members had a medical recordand those less than 50 per cent of whose
members had such a record. The difference between urban and rural users w a s
striking, as is shown in Table 1.

TABLE 1.

Utilization
Households A B C
OSigh: (Low; (Residual
90 per cent) 50 per cent) of A and B )

Urban 32.3 12.1 55.6

Rural 13.1 29.9 57.0
404 Amor Benyoussef

Statistical analysis revealed that those w h o m a d e extensive use of the health

services were generally m o r e literate than those w h o did not, and that socio-
cultural and economic differences existed between the two categories. In the urban
and rural households studied, frequent users of the services were in general better
acquainted with the means of preventing communicable diseases. O n the other hand,
respondents w h o lived in rural zonesparticularly those w h o rarely m a d e use of the
servicescomplained that relations between physicians and patients and the care
and medico-social advice provided were inadequate.
T h e study suggests that the utilization of health services m a y be regarded as
an indicator of modernization and, hence, that improvement in health m a y depend
not only on the impact of the health services but also on the process of change in
society. This is an important issue for almost 80 per cent of the world's population
and shows that the future development of health and education must be linked with
overall development, of which community primary health care would form an
integral part. This would entail adapting health and other aspects of devel-
opmentsuch as education, agriculture, environmental health and transportto
the needs of the population.
T o the extent that the population studied in Tunisia is representative of
developing countries, the survey supported these conclusions. It demonstrated
that: (a) utilization of health services is low in comparison to that which has been
observed in more developed countries; ambulatory health services are used most
often for treatment of the c o m m o n communicable diseases, and 85 per cent of all
patients are seen only once per episode of illness; (b) although some health services
were available and accessible freely to all the population studied it was estimated
that only 50.5 per cent utilize them in a given year; (c) utilization rates are strikingly
higher a m o n g urban than rural residents; (d) respondents from high-user households
were especially likely to have the following characteristics: urban residents w h o were
literate had cultural traits such as reading newspapers, speaking French, watching
television and participating in social and economic meetings. They tended also less
often to admit being influenced by traditional medical practices, believed in the
capabilities of modern medicine to prevent as well as treat illness, and were satisfied
with the health services.

Health, migration and urbanization

For m a n y years it has been noted that urban life is associated with an increased risk
of disease. Greenwood, 9 writing in the 1920s, attributed some of this increased risk
to crowding, and consequent increased transmission of infectious diseases; both
epidemiological and experimental10 studies provided strong support for this
hypothesis. M o r e recently11 it has been noted that m a n y chronic, non-infectious
diseases occur more frequently a m o n g urban residents. This difference cannot be as
 Health service delivery in developing countries 405

easily explained, and several theories have been put forward as to w h y urban life
poses a hazard to health. They generally fall into two categories: (a) that increased
risk of disease is attributable to environmental contaminants found in urban areas
and (b) that persons migrating from rural to urban areas are exposed to deleterious
social stress. The latter hypothesis has served to m a k e a useful distinction between
the health of urban dwellers generally and that of persons w h o have migrated to the
city.
Large-scale migration to cities is occurring throughout the world, particularly
in the developing countries. In order to clarify the health consequences of such
migration, the World Health Organization has promoted several pilot studies.12
There are several ways whereby urban life could have deleterious health
effects:
Environmental contaminants existing within a city m a y cause new diseases or
aggravate existing conditions. T h e urban migrant finds himself exposed to such
potential health hazards as air and water pollution, heavy traffic, and occupational
hazards that he has not experienced in the rural area. According to this hypothesis,
one would expect to find an increase in specific diseases associated with certain
environmental contaminants. Also, within the urban area there might be observed
a gradient of disease, depending on the concentration of the contaminants. This
approach also implies that the migrant's health would be no worse than that of the
other urban dwellers. There is evidence that severe and unusual environmental
hazards m a y produce acute increases in mortality for m a n y causes, for instance
the 1966 Eastern Seaboard air pollution experience13 and certain conditions such as
chronic bronchitis have been related to air pollution in several countries. T h e fact,
however, that almost every cause of mortality and morbidity is increased in m a n y
urban areas argues against the specific impact of environmental contaminants.
Finally, there is evidence that disease rates are higher in farm-born persons w h o have
migrated to cities, than amongst the urban-born. 14
That crowding and more numerous social contacts m a y afford greater
opportunities for the transmission of infectious diseases has recently been critically
analysed by Cassei,15 w h o has pointed out that the relationship between crowding
and health is far more complex than originally envisaged. If crowding simply
resulted in increased transmission of infectious diseases, then the urban dweller
should have higher rates of these diseases only, particularly those that are airborne.
But, as already noted, the rates for almost every disease are higher a m o n g urban
dwellers. This theory is also difficult to evaluate because crowding is associated with
other health hazards such as poor nutritional level and unavailability of adequate
medical care. Finally, little is k n o w n about detailed social networks of persons w h o
migrate to cities. It is conceivable that some migrants experience fewer social
contacts after adopting urban life.
Adequate health care in a rapidly expanding urban area is certainly a major
problem for the urban communities of the developing countries. Yet, in these same
406 Amor Benyoussef

countries rural health services are even less developed, and it is more typical for a
migrant to go from a rural area where there is virtually no medical care available, to
an urban area where there is some, however inadequate. Furthermore, migrants m a y
be different from the general population with respect to disease levels. It is well
k n o w n that cities attract sick persons because of their medical care facilities.
Stallones1* has pointed out that within the United States there is a positive corre-
lation between the physician-population ratio and mortality from coronary heart
disease. There is no evidence, however, that most migrants go to cities because of an
illness. This effect could operate in a more subtle w a y if the migrant differed from
the non-migrant by having higher levels of genetic or acquiredriskfactors. It would
be very important, therefore, to study the health status of migrants before they even
decide to migrate. Such a study, n o w being conducted in the Tokelau Islands, m a y
indicate whether this is an important factor.
Finally, the notion that has gained considerable support in recent years is that
social change s o m e h o w imparts a risk to disease. S y m e has written extensively about
the relationship between coronary-heart disease and mobility.17 The mobility m a y
be generationalmen living in adult circumstances which are quite different from
those in which they were reared; persons w h o have changed jobs frequently seem to
have higher disease rates; as d o those w h o change their residence often; and those
w h o do not m o v e themselves, but whose world moves about them. Increased risk
of coronary heart disease has been attributed, as S y m e has put it, to moving from a
world where the rules of the g a m e are clear and k n o w n to one where different and
u n k n o w n rules apply. Henry and Cassei18 have reviewed a considerable body of
experimental animal investigations that tend to support the idea of patho-
physiological mechanisms responsible for this increase of disease, which remain to
be elucidated, although there is some evidence that complex hormonal changes are
involved.
Such ideas about social stress have generated interest in h o w the migrant
adapts to urban life and whether those w h o adapt easily and quickly experience
fewer health problems than those w h o adapt poorly. W h a t can help a migrant to
cope? It is intuitively appealing that social support such as having family or friends
already in the urban area or the availability of community agencies m a y ease the
migrant's adaptation. S o m e support for this hypothesis comes from a recent study
at the University of North Carolina, where it was found that pregnant w o m e n w h o
experienced a life crisis had far fewer complications of delivery if they possessed
psycho-social assets.19
There are a number of methodological problems that must be solved in
studying the health effects of urban migration. A somewhat ideal study might
measure relevant health and social factors in a cohort of rural people before they
have decided to migrate, remeasure these factors after the decision to migrate has
been taken but before migration actually takes place, and then continue to remeasure
these factors at intervals after arrival in the urban area. Repeat examinations would
 Health service delivery in developing countries 407

have to be done on different samples of the cohort since the examinations themselves
might influence adaptation and such a study would be very long-term. It is unlikely
that a large-scale study of this type would be feasible. A compromise used on a
number of occasions has been to compare rural to urban residents. A refinement
of this approach is to compare rural people to similar people w h o have migrated
to the city, and a further refinement would be to try to measure adaptation to urban
life and relate this measure to the health of urban residents. Both these latter
approaches were attempted in a study in Senegal.

The Senegal study: methodology and findings

The Senegal Collaborative Study80 was carried out from 1970 to 1973 by W H O ,
the University of Dakar, and the Office de la Recherche Scientifique et Technique
Outre-Mer, Dakar-Centre, with the technical assistance of the Ministry of Public
Health and Social Affairs and other ministries of Senegal. Its object was to assess
the effects of urban migration on the health of a sample of Serer migrants from the
rural district of Niakhar, some 100 kilometres from Dakar, w h o were resident in the
city at the time of the study. The urban sample was compared to a sample of the
rural population of Niakhar from the triple viewpoint of socio-demographic
situation, physical and mental health, and housing and the immediate environment.
The analysis offindingsfrom the urban sample included the identification of some
of the factors associated with adaptation to urban life.
In the non-medical parts of the study,21 the demographic, economic and socio-
cultural aspects of urban migration were investigated. The distribution by age group,
sex and marital status showed that the urban migrant population tends to be younger
than the rural population and that it includes twice as m a n y single females. Tra-
ditional religious practices remained important in the rural area but decreased in
significance in Dakar a m o n g the urban migrants; this m a y reflect the greater
influence of Islam a m o n g the urban population. A s might be expected, the edu-
cational level, as measured by school attendance and number of years spent in school,
was m u c h higher a m o n g urban than a m o n g rural dwellers; it was also markedly
higher a m o n g adult males than females. Comparisons of socio-economic conditions
between the rural and urban samples showed differences in diet, food, consumption,
clothing, and housing that reflect a change in attitudes and behaviour as a conse-
quence of acculturation and urbanization. Finally, the way in which rural and urban
dwellers perceived and dealt with health problems did not differ greatly. However,
while males migrating to the city continued to trust both folk and modern therapy,
females in Dakar tended to believe more in modern medicine.
Three areas of medical concern were studied in particular:22 precursors of
coronary heart disease ( C H D ) , anaemia, and infectious diseases. Little difference
was observed between rural and urban populations for most of the precursors
408 Amor Benyoussef

of C H D measured, except that the urban samples had higher levels of cholesterol and
the males smoked more cigarettes. Anaemia was more c o m m o n in the rural area
in both sexes. A m o n g infectious diseases, malaria, intestinal parasites, and
tuberculosis were more prevalent in the rural sample. Schistosomiasis was quite
c o m m o n in both the urban and rural samples. Mental health was assessed through
a questionnaire covering various psychiatric conditions of a mild, moderate or
severe nature and by subsequent evaluation procedures. In general, the frequency
of these conditions was similar in the urban and rural populations, though psycho-
physiological reactions and brain syndromes were more c o m m o n a m o n g the urban
sample, whereas depression and fatigue were more c o m m o n a m o n g rural people.
There was no difference in the rate of anxiety between the two groups. It also appears
that there m a y be certain groups, such as young single w o m e n , w h o have difficulty
in adapting to urban life and m a y be at a high risk for certain diseases. If a subsequent
study should bear this out, such groups might well benefit from special social
services.

Primary health care

In a recent publication23 of the World Health Organization it was suggested that

primary health care could be called 'Health by the People', which can be both a
philosophical and a practical idea. Philosophically one can believe that community
organizations, using their powers of self-determination, should be the starting point
of health care services. Practically, since there is seldom enough m o n e y in most
developing countries to consider any other course of action, community organ-
ization must be the starting point.
Primary health care is an approach shaped around the population it serves.
It uses methods and techniques that are appropriate, inexpensive and acceptable
to the community. In so far as possible, the m a n p o w e r , materials and funds for the
project are generated from within the community itself. T h e major efforts of
primary health care are undertaken at the most peripheral community level prac-
ticable. However, it should at the same time be an integral part of the regional or
national health system and should be fully integrated into the national health
system. The W H O publication listsfivefunctions for community organizations:
setting priorities, organizing community action for problems which cannot be
resolved by individuals (for example, water supply and basic sanitation), legitimizing
the primary health care worker,financiallyassisting the services, and linking health
activities to wider community goals.
The community can set health priorities, by using the fourfold criteria of
community concern for the problem, its seriousness, its point prevalence and its
susceptibility to management. 2 4 Once the priorities are determined, appropriate
action can be taken, requiring primary health care workers w h o can be selected,
 Health service delivery in developing countries 409

trained, financed and inspired by the community. The concept of the primary health
care worker is, by n o w , well k n o w n . This worker is neither a doctor, a nurse, a
sanitary engineer, nor a nutritionist but, to an extent, performs at a local level some
of the duties of each of these roles.25 T h e fact that he is a trusted and accepted m e m b e r
of the community is often as important as his training.
It has been found 28 that in time the primary health care worker, along with
the community organization, comes to recognize the binding relationship between
specific local health problems and to an extent, the wider regional socio-economic
situation in general. Urban malnutrition, for example, can be seen to be closely
connected with food production in the rural areas of the country which, in turn, m a y
be linked to the political situation as in China or the United Republic of Tanzania.
It should be noted that primary health care and the primary health care worker
depend on the use of feasible modern scientific knowledge and health technology,
as well as on accepted and effective traditional healing practices and linkage with
other tiers of the health advice system, from which the primary health care worker
should have adequate supervision, referral services for his patients and training
facilities.
A review article27 dealing with the literature of primary health care deplores
that most material lacks documentation and often extols one form of primary health
care at the expense of another. T h e review concludes that the literature can
be divided into three groups: conceptual and methodological, evaluative and
descriptive.
The conceptual articles are primarily technical, often theoretical works which
m a y never be transformed into working systems. The evaluative literature describes
the frustrations of attempting to perform statistical analyses on non-quantifiable
data. Descriptive papers m a y be distorted by the political viewpoint of the author.
In general, one could say that most inquiries into primary health care are still in the
developmental stage. However, this need not be disquieting, since primary health
care is a service to the people, attempting to meet their needs, which properly bears
little relation to cold, impassionate, impersonal 'science'.
O n e recent publication28 devises a framework for categorizing methods of
measuring the various aspects of the quality of health care. This approach could
perhaps be useful in making decisions regarding where and h o w to expand services.
T h e great bulk of literature on primary health care falls into the third or
empirical descriptive category. In the following section w e shall adopt this approach
to present a selection of currently existing primary health care activities, chosen to
represent a broad range of types and a variety of ecological, socio-economic and
political settings.
Before doing so, however, it is worth noting that in a recent publication29 the
World Bank Group discusses primary health care in relation to rural economic
development. Independently and at a technical level, this reaches nearly the same
conclusions as the W H O / U n i c e f group concerning the need for primary health care
410 Amor Benyoussef

and the importance of linking it to the other aspects of rural development. 30

O n e of thefindingsis that the health conditions of the poor everywhere are
basically similar. Their core disease pattern consists of the faecally-related and
air-borne diseases and malnutrition. Together these account for the majority of
deaths a m o n g the poorest people in developing countries. T h e study notes that there
is a marked association between the per capita income in a developing country and
its health status and that one way to raise the general level of health in a region is
simply to raise its standard of living. This relationship between per capita income
and health can be seen in comparing certain African countries, which have the
lowest per capita incomes and report the lowest levels of health, to certain Latin
American countries, which are a m o n g the wealthiest of the developing nations, and
have health conditions approaching those of the developed world. It is concluded
that:81

public health expenditures to improve the quality of life of the poor can be justified on
moral and economic grounds, although the complex and dynamic interaction of
demographic, social and cultural forces affected by the health workers make it difficult to
say, on economic grounds, how large such expenditures should be.

Some illustrative country experiences

China: a persuasive health approach

In China, the entire population has been fundamentally oriented towards disease
prevention and primary health care through the guiding inspiration of the top
political leadership, particularly the late Chairman M a o Tse-tung. 82 In the early
1950s and 1960s, mass health and sanitation campaigns were organized to secure
the personal involvement and commitment of each individual as a patriotic duty to
the country and to himself. M a s s education drives instructed people to build
sanitation facilities and keep their neighbourhoods clean. Everyone was encouraged
to practise preventive health care, to 'fight against his o w n disease' as an enemy to
be conquered, and to help his neighbours.
In 1965, Chairman M a o issued the 'June 26 Directive' which put the spotlight
on the health needs of China's large rural population and on the inability of the
existing health services to provide for them. This led to the so-called 'barefoot
doctors', locally recruited rural youths w h o receive three months of formal training
in the use of both traditional Chinese and Western medicine, followed by supervised
on-the-job training. The 'barefoot doctors' serve in the rural c o m m u n e s as regular
agricultural workers, and provide health care on a part-time basis to the production
teams (the smallest subdivision of a c o m m u n e into which all of rural China is
divided) each of which numbers from 100 to 200 people. Each c o m m u n e supervises
between ten and thirty production brigade health stations covering 500 to
3,000 people. T h e care provided by the 'barefoot doctors' includes treatment of
 Health service delivery in developing countries 411

minor illnesses, prevention and health education in both health stations and in the
fields; in addition they supervise volunteer health aids w h o deal with sanitation
problems.
There are n o w over a million 'barefoot doctors' in China, not counting the
analogous worker doctors in the factories and the R e d Medical Workers active in
every city lane. O n e of the most important tasks of China's health workers is the
reduction of the birth rate, which has been quite successful due to constant vigilance,
person-to-person contact and educational activities.
Because primary health care is part of the national health system which is
administered in decentralized fashion at the community level, health facilities are
locally planned and financed and the benefits differ somewhat in the urban and the
rural settings. Urban factories maintain health and welfare funds to which are
allocated respectively 10 per cent and 2-3 per cent of total salaries; these per-
centages are said to be 'mandated by the State' and are not considered as tax
deductions from wages. Workers' health treatment expenses are free, as they are
charged against the fund, whereas neighbourhood lane clinics meet their expenses
by charging a fee to patients, except in those clinics where a 'co-operative medical
system' has been introduced and patients pay only an annual premium.
In rural China, some 70 per cent out of the production brigades n o w have a
co-operative medical care system, where each m e m b e r w h o desires coverage
contributes afixedannual amount which is supplemented by contributions from
the production brigade and, in some cases, from the production team welfare funds.
There are considerable variations, so that while under some arrangements all the
needed services are thus covered, in others a small additional visit fee is charged.
For most visits to the doctor in China, including visits to the 'barefoot doctor',
the patient must pay at least a small 'registration fee'.
Primary health care appears to be an essential echelon integrated into the
highly structured Chinese national health system. A s such, it is an important element
in the system's stated priority to provide accessible health care to all, particularly to
those w h o had no access to it in the past.
Perhaps the most remarkable feature of the primary health care programme
in China is the extent of its coverage. With its linkage to the mass health popular-
ization campaigns in their emphasis on the strengthening of health care in rural
areas, where 85 per cent of China's population live, its pervasive roots anchored in
the population of closely knit neighbourhood, team and local residents' health
stations, the Chinese P H C programme appears to have developed a comprehensive
network for professional, supervised and responsible health care at the grass roots,
on the w a y to achieving practical full health care coverage for China's large
population.

United Republic of Tanzania: population relocation helps simplify medical care

Primary health care in the United Republic of Tanzania is being promoted in the
412 Amor Benyoussef

framework of the government's commitment to improving basic health services in

the rural areas as a n integral part of the country's overall socio-economic
development.'
A major obstacle to the development of this large country has been the widely
dispersed situation of its population. Recently, an original attempt was m a d e to solve
this problem by grouping the population into larger, economically viable c o m m u n i -
ties called Ujamaa villages, consisting of 100 to 500 families working together
collectively. This strategy has greatly facilitated the provision of essential amenities
such as wholesome water and basic health services, as well as raising farm pro-
ductivity; these villages also serve as bases for mass health and sanitation campaigns
and help m a k e easier the treatment of communicable diseases and the health edu-
cation of the population.
Nation-wide emphasis is placed on self-reliance and disease prevention. There
is strong community participation in planning and villagers' involvement is encour-
aged in the construction of their o w n health facilities, such as health posts, of which
there is one in each village. They choose and support their o w n medical helpers, w h o
staff the health posts and provide treatment for minor ailments. Other primary
health care facilities include rural dispensaries (one for 600 to 8,000 inhabitants)
which provide higher-level diagnosis and treatment as well as maternal and child
health services and mobile health teams which provide health care in areas where
institutional coverage is very thin.
Since this young programme started ( 1972/73), it has already achieved primary
health care coverage of over 3 million people by health posts in some 5,500 Ujamaa
villages, and about 13 million people are served by 1,555 dispensaries, backed
up by 69 health centers and 128 hospitals; it is vigorously progressing towards
fuller and more comprehensive coverage. T h e Tanzanian primary health care
programme has met with considerable success and, due to its heavy emphasis on
minimization of cost and its relatively modest resource requirements, its approach
offers great replicability, particularly for certain neighbouring African countries
which have been co-operating in various aspects of health services.

Venezuela: a pyramid of simplified health care

Primary health care in Venezuela is identified with the 'simplified medicine' scheme
adopted in 1962 by the Ministry of Health, as an organized and homogeneous effort
to provide basic health care to the country's dispersed rural population.31 T h e
programme grew out of the pressing and hitherto unmet need for health care by
people living in scattered, remote areas and for w h o m , due to the shortage of
trained health staff and other facilities, there was no hope of obtaining professional
medical attention. T h e scheme represents a simple, practical approach to the
provision of at least some rudiments of health care and attention to the rural
population.
Primary health care in the 'simplified medicine' scheme is essentially pre-
 Health service delivery in developing countries 413

ventive and curative and is based in a network of village dispensaries or rural health
posts, each one staffed by one auxiliary health worker specially trined for the job.
They are the 'front line' integral part of the developing National Health Service
which is itself anchored on the centrally administered regional network of the
'Co-operative Health Service', extant in thirteen out of the twenty-three political
units of the country and comprising three other higher levels, considered as a
necessary supporting structure for the community based front line. These include:
the medicatora or rural health post staffed with a doctor and a few auxiliaries and
providing medical care to semi-rural and intermediate populations and support for
the peripheral level, including sick beds in areas of reasonably high population;
the health centre, which is the focal point of the health district (of which there are
eighty-five throughout the country) offering regular hospital facilities and pro-
fessional staff for basic medical services; and a fourth level, represented by the
State and/or regional services providing specialized hospital facilities (mental,
tuberculosis, etc.).
The health auxiliary is the essential primary health care worker in Venezuela.
H e or she staffs the rural dispensary, serving from 500 to several thousand people,
and must be on call at all times for emergencies, in addition to the regular eight-hour
work day. T o be selected for training a candidate must be aged 18-40, a permanent
resident in the locality of action, be acceptable to the local leaders, and have had
six years of primary schooling. Training lasts four months and is geared to a
detailed manual of instruction, complemented by a period of in-service training
with the nurse-supervisor. Emphasis is placed on the ' h u m a n ' approach, confiden-
tiality of patient treatment and on the observance of the limits of the auxiliary's
competence by referring complex cases to higher levels of service. The training period
is sanctioned by a formal certificate to the effect that the auxiliary can perform his
functions only in a rural dispensary under the regulations of the health service. In
the auxiliary's duties, maternal and child health has priority. This calls for regular
follow-up of pregnant w o m e n , encouragement of institutional deliveries, supervision
in the hygienic and prophylactic procedures of local midwives and collaboration
with them for h o m e visits in cases of h o m e deliveries. Another major function of
the auxiliary is carrying out curative treatment of illness cases he is able to identify.
Health education is given to waiting patients, through h o m e visits, special mothers'
classes, children's clubs and community meetings. Other functions include
registration of vital events (unofficial) and vigilance concerning certain c o m m u n i -
cable diseases.
Auxiliaries have been increasingly playing roles of promoters of the general
well-being of communities, spurring o n community developmental activities such
as h o m e and agricultural improvement and some have become the real leaders in
the community. A t the end of 1973, 792 health auxiliaries had been trained and the
P H C network numbered 315 dispensaries and 496 medicaturas, covering an esti-
mated population of 280,000 (out of a rural total of 2.3 million). The programme
414 Amor Benyoussef

is government-financed but communities are encouraged to participate in the

maintenance and running costs of the dispensaries and contribute in kind for
their construction and equipment.
The 'simplified medicine' scheme has the merit of making operational a
comprehensive alternative to the previous situation of a chaotic plethora of unrelated
and gap-ridden health care schemes. Although its progress has been slowed d o w n
by administrative and staffing problems, it has managed to extend health care
coverage to m a n y previously neglected areas and has been well received and utilized.

Cuba: a political approach to health problems

At present C u b a has a health service system available to nearly all of its population,
with a referral system ensuring that each patient receives the appropriate level of
care. This has not always been the situation. Before 1959, a considerable part of the
rural population had n o access to any form of health services. The change has come
about because of the political revolution in 1959, after which time health care was
considered an excellent political investment. Health services are free and run by
the State on the principle that the health of the population is a government responsi-
bility, that health services should be available to the total population and the
community should actively participate in health work.
Numerous auxiliary personnel were trained and, in 1961, the decision was
m a d e to require six months' service in rural areas by all n e w medical graduates.
Measures were taken to achieve complete geographical and population coverage in
the whole country. The curative doctor of former times has been replaced by a corps
of workers with a comprehensive view of medicinepreventative, environmental,
rehabilitative and curative. Perhaps even more decisive for health has been the food
distributed to the population. Impressive results have been seen in some areas. For
example, mortality from diarrhoeal diseases dropped from 68 deaths per
100,000 population in 1962 to approximately 15 per 100,000 population in 1972.
Other health indices have also improved, but not so dramatically. T h e infant
mortality rate was 33 in 1958 and 27 in 1973, and the crude death rate has dropped
from 6.5 to 5.8 in the same period.

Niger: voluntary workers help keep health expenses low

The Republic of Niger has been relying on voluntary workers to cover the elementary
health needs of populations living in remote areas. In 1963, thefirstvillage health
workers were trained to give basic treatment, develop hygiene and improve basic
nutrition in their villages. By 1970, various pilot projects were integrated, training
was gradually extended and organized so that by 1974 Niger had 780 village health
workers and 467 village midwives. A t the same time, rural dispensaries were
upgraded to rural health centres where regional health action plans could be
devised, the midwives and village workers trained and continuing education carried
on. Cost is kept to a m i n i m u m since the village health workers are volunteers and
 Health service delivery in developing countries 415

are not paid. T h e only expenses are for the training and refresher courses, the
medical supplies and the petrol used in transporting the worker and the supplies.
In 1970 a pilot project was initiated in the Department of Marodi where the
major diseases were infectious or parasitic and infant malnutrition was widespread.
Village pharmacies were opened and village health workers and birth attendants
trained. Once a month the village pharmacy is supervised by a nurse from the
nearest health establishment w h o checks the general state of cleanliness of the village,
replenishes the supply of free drugs and checks on any incompetence or unwillingness
shown by the village health workers. T h e improvement in health care at the village
level is such that it is rare for a village to refuse to develop its o w n set of village
health workers.

Sudan: a multi-disciplinary approach to primary health care

In 1975 an in-depth study was m a d e on health programming following which the
Sudan, with the assistance of W H O , prepared a 'National Health Programme'. 3 6
T w o related long-term plans also prepared with the assistance of W H O deal specifi-
cally with the problem of primary health care in the Southern Region and the four
other regions of the country, particularly in the least favoured provinces of the east
and west in which the population is mainly rural and nomadic. 36
These studies evaluate methods and procedures used in the Sudan for the
national programming and formulation of the primary health care programme.
Within this framework health programming and health programme formulation
depend upon the global decision-making process based on technical, demographic,
cultural, socio-economic,financialand political/administrative considerations. In
practice programme formulation activities took into consideration broader indi-
cators which inspired the Sudan studies with a truly intersectoral approach.
This approach was designed within the overall framework of socio-economic
development, using the following steps: definition of objectives, preparation of
strategies, analysis of constraints inherent in these strategies, development of health
programmes out of these strategies, estimates of cost in terms of development
(capital) and recurrent expenditures, establishment of timetables for pre-
implementation and implementation phases.
This methodology included also the development of criteria and setting of
objectives for the primary health care programme as a whole, defining strategies for
rural and nomadic populations, analysis of constraints andfixingtimetables, and
finally making programme cost estimates on an annual basis.
T h e Sudanese experience illustrates h o w pertinent and important factors
other than purely medical can be, especially in terms of strategies for coverage of
rural and nomadic populations. These strategies will rely heavily on the partici-
pation of the population within the overall framework of community development
schemes.
416 Amor Benyaussef

Conclusion
During the past decade various individual groups and some governments and
international organizations have approached the massive problems of poverty,
sickness, disease and death, via the route of primary health care. In some cases,
existing services were extended from urban centres out to the villages, in others
series of interconnected political, economic and social measures, were introduced,
while others still started with basic improvements at the village level. T h e methods
used were not the same, yet in each instance a degree of success can be reported.
B y the use of simple, basic health techniques and the provision of food, education
and assistance in financing, the health of m a n y communities has dramatically
improved. 87 N o n e of these contrasting approaches include enough data to m a k e it
possible to say that any one method is quicker, cheaper or more effective than
another one. All are, to some extent, successes when viewed from within (i.e. by their
o w n subjective criteria) yet not all appear viable, or even beneficial, in the long-term.
Nevertheless, it is encouraging to note that the possibility for change does exist and
that there is no single method that is universally applicable.
There are several questions that can legitimately be asked concerning primary
health care.
Is it true that primary health care is the best approach in developing countries?
It is at least one approach and action is generally preferable to inaction. If the choice
is between offering primary health care or no health care at all, then the answer is
obvious.
Is primary health care merely another passing fad in medical care, or is it the
wave of the future? In certain countries (China, Venezuela and the United Republic
of Tanzania for example), primary health care is so well entrenched that it is hard to
think of it as a transitory phenomenon. In other countries the reverse m a y be true.
Should one be optimistic about the results of primary health care? Achieve-
ments in basic health are usually determined by the dedication of the planners and
implementation of the health schemes. In some cases the results have been highly
rewarding, in others disappointing. Projects that were realistically conceived, well
planned and highly motivated, usually succeeded. Others, lacking these basic
ingredients, often failed.
W h a t are the areas of primary health care that need further attention?
Co-ordination of local, regional and national health efforts needs to be refined and
improved; training courses for the primary health care worker must be maintained
and brought into focus; coverage should be continuously extended until all segments
of the population have access to health care services.39
W h a t lessons can be learned from national primary health care experiences?
Primary health care is not an easily obtainable goal. It requires years of trial, error
and sometimes even failure, to attain a workable and manageable system. It is
necessary to persevere through seemingly insurmountable obstacles if the goal is to
 Health service delivery in developing countries 417

be reached. Patience and endurance, more than energy and daring, m a y be the
h u m a n qualities needed to instigate and bring to fruition a primary health care
system in developing countries.
The experience in Africa, Latin America and Asia over the past ten years points
to the need for a multidisciplinary approach where health priorities are understood
within the general framework of rural development. Such an approach permits
epidemiologists and administrators as well as socio-economic planners, social
scientists and statisticians to contribute to a better understanding of complex
socio-medical priority problems. This understanding must be the basis for health
policy-making within the overall development process.
Over the past twenty years, the African, Latin American and Asian experience
in thisfieldpoints to the need for a close time of situational analysis and action. This
essentially implies an emphasis on modifiable factors in research and development,
together with an effort to minimizefinancialand h u m a n costs compatible with the
scarcity of resources and management constraints.39

Notes

1 11
J. Bryant, Health and the Developing World,
Ithaca, N . Y . , Cornell University Press, 1969.
2
R . A . Stallones, 'Environment, Ecology and Epi-
demiology', WHO Chronicle, Vol. 26, 1972,
p. 294-8.
3
G . Myrdal, Asian Drama: An Inquiry into the Poverty
of Nations, N e w York, Pantheon, 1968.
4
M . G . Candau, ' W H O and Socio-Economic
Development', WHO Chronicle, Vol. 25,
1971, p . 441^1.
6
B . Christian, D . Ray, A . Benyoussef and T . Tana-
hashi, 'Health and Socio-Economic Develop-
12
ment: A n Intersectoral Problem', Social
Science and Medicine (in press).
6
Health Care: An International Study, Oxford Uni-
versity Press, 1975.
7
R . Grass, 'Primary Health Care: A Review of the
Literature Through 1972', Medical Care,
13
Vol. XII, N o . 8, August 1974, p . 638-47.
8
A . Benyoussef and A . F . Wessen, 'Utilization
of Health ServicesTunisia', Social Science
and Medicine, Vol. 8, 1974, p . 287-304;
14
A . Benyoussef, A . F . Wessen, T . Phan Tan
and H . Souissi, 'Services de Sant : Couver-
ture, Facteurs et Indices d'Utilisation', Bulle-
tin de l'Organisation Mondiale de la Sant,
Vol. 51, 1974, p . 111-32.
9
M . Greenwood, Epidemics and Crowd Diseases, 1 5
16
N e w York, Macmillan, 1935.
10
L . T . Webster, 'Experimental Epidemiology',
Medicine, Vol. 25, p . 77, 1946.
N . A . Scotch, 'Socio-cultural Factors in the Epi-
demiology of Zulu Hypertension', Am. J.
Publ.HIth.,Vol.53,1963,p. 1205;S. L . Syme,
M . M . H y m e n and P . E . Enterline, ' S o m e
Social and Cultural Factors Associated with
the Occurrence of Coronary Heart Disease',
/ . Chron. Dis., Vol. 17, 1964, p . 277;
J. Cassei, 'Health Consequences of Population
Density and Crowding', Population Growth,
Consequences and Policy Implications, chap-
ter XII, Baltimore, M d . , John Hopkins Uni-
versity Press, 1971.
A . Benyoussef, 'L'tude de la Sant des Migrants
en Ville', Proc. Colloques internationaux du
CNRS, la Croissance urbaine en Afrique Noire
et Madagascar, Bordeaux, Oct. 1970,
p. 93-110, Paris, ditions du Centre national
de la Recherche scientifique ( C N R S ) , 1972.
M . Glasser, L . Greenburg and F . Field, ' Mortality
and Morbidity during a Period of High Levels
of Air Pollution', Archs Environ. Health,
Vol. 15, 1967, p . 684.
Syme, H y m e n and Enterline, op. cit.; W . Haenzel,
D . B . Loveland and M . G . Sirken, 'Lung
Cancer Mortality as Related to Residence and
Smoking Histories', / . Nat. Cancer Inst.,
Vol. 28, 1962, p . 947.
op. cit.
R . A . Stallones, 'Environment, Ecology and Epi-
demiology', WHO Chronicle, Vol. 26, 1972,
p. 294.
 418
Notes (.continued)
17
Syme, H y m e n and Enterline, op. cit.; S. L . Syme, 28
N . O . Borhani and R . W . Buechley, ' Cultural
Mobility and Coronary Heart Disease in an
Urban Area', A m . J. Epidem., Vol. 82, 1965, 28
p. 334.
18
J. P . Henry and J. C . Cassei, 'Psychosocial Fac-
tors in Essential Hypertension: Recent Epi-
demiological and Animal Experimental Evi-
dence', Am. J. Epidem., Vol. 90, 1969,
p. 171.
19
K . B . Nuckolls, J. Cassei and B . H . Kaplan,
'Psychosocial Assets, Life Crisis and the
Prognosis of Pregnancy', A m . J. Epidem.,
Vol. 95, 1972, p. 431.
20
A . Benyoussef et al, 'Health Effects of Rural/
Urban Migration in Developing Countries
Senegal', Social Science and Medicine,
Vol. 8, 1974, p. 243-54; A . Benyoussef et al.,
'Sant, Migration et Urbanisation : U n e 33
tude Collaborative au Sngal', Bulletin de 34
l'Organisation Mondiale de la Sant, Vol. 49, 35
1973, p. 517-37.
21
ibid.
22
ibid.
23
K . Newell (ed.), Health by the People, World
Health Organization, Geneva, 1975.
24
Barbara S. Hulka and John C . Cassei, 'The
A A F P - U N C Study of the Organization, Util-
ization and Assessment of Primary Health
Care', American Journal of Public Health,
Vol. 83, June 1973, p. 494-501.
25
Thomas W . Bice, Kerr L . White, 'Factors Related
to the Use of Health Services: A n Inter-
national Comparative Study', Medical Care,
Vol. VII, N o . 2, March/April 1969, p. 124-33.
23
Kerr L . White, 'Primary Medical Care for F a m -
ilies^Organization and Evaluation', The New
England Journal of Medicine, Vol. 277, N o . 16,
October 1967, p. 852-74.
27
J. Broyelle, L . Brams, F . Fagnani and L . Tabah,
'Recherches sur les Besoins de Sant d'une
Population', Bulletin de l'INSERM T.,
Vol. 24, 1969, p. 613.
Amor Benyoussef
K . Smith, 'Health Priorities in Poorer Countries',
Social Science and Medicine, Vol. 9, 1975,
p. 121-3.
World Bank Group, The Assault on World Pov-
erty, Problems of Rural Development, Edu-
cation and Health, Baltimore, Johns Hopkins
University Press, 1975.
30
V . Djukanovic and E . P . M a c h , Alternative
Approaches to Meeting Basic Health Needs in
Developing Countries: A Joint UNICEF/WHO
Study, Geneva, World Health Organization,
1975.
31
World Bank Group, op. cit.
32
Jerome S. Belofif and M . Krper, 'The Health
T e a m Model and Medical Care Utilization',
Journal of the American Medical Association,
Vol. 219, N o . 3, 1972; WHO Chronicle,
Vol. 29, M a y 1975.
ibid.
ibid.
Sudan, Democratic Republic of, National Health
Programme 1977 78-1983 84, Khartoum,
1975.
36
Sudan, Democratic Republic of, Primary Health
Care Programme, Southern Region, 1977/78-
1983/84, Juba, 1976; Sudan, Democratic
Republic of, Primary Health Care Programme,
Eastern, Northern, Central and Western Re-
gions, 1977/78-1983/84, Khartoum, 1976.
37
Newell (ed.), op. cit.; Djukanovic and Mach,
op. cit.
38
F . Schofield, 'Health Planning in Developing
Countries', Impact of Science on Society,
Vol. X X V , N o . 3, 1975; A . A . Idriss,
P. Lolik, R . A . Khan and A . Benyoussef,
'Sudan: National Health Programme and
Primary Health Care, 1977/78-1983/84',
Bulletin, World Health Organization, Vol. 53,
N o . 4, 1976, p. 461-71 (see also by same
authors 'The Primary Health Care Programme
in Sudan', World Health Organization Chron-
icle, Vol. 30, 1976, p. 370-4).
39
ibid.
 Strengthening health information services

A . S. Hr

Introduction

In the healthfield,technological progress has revolutionized preventive, curative,

diagnostic and numerous other branches, the overall benefits of which are unde-
niable, yet one must note that there has been n o comparable progress at the
ideological level. Consequently, the administration and management of health-
related activities have not 'exploded' in the same way as these branches, which is
definitely not due to the absence of an applicable technology. Modern data-
processing methods have m a d e possible things which were simply Utopian a gener-
ation ago. Though economic and other resource limitations m a y be reasons for the
slow development, one can postulate that it is chiefly due to negative attitudes and
lack of interest.
While such broad claims cannot be strictly proven, a general feeling of this
kind is quite widespread a m o n g those w h o administer health and health-related
services. There is n o k n o w - h o w and n o power to build a system which covers all
relevant needs and all persons in need. In the United States of America it is even
customary to refer to a 'non-system' in relation to health services (Neuhauser, 1976).
In other countries the same is said in less dramatic terms. A kind of summary of
world opinion was expressed at the World Health Assembly in 1973, where it was
concluded that in both developed and less-developed countries it was commonly
felt that health services are not fulfilling expectations. Attention should be drawn
especially to the recommended remedial action, that there is reason to apply
modern, 'scientific' management to health administration. Especially stressed was
the need to improve information serving such purposes ( W H O , 1973):

Dr A . S. Hr is Director of the Department of Planning and Evaluation of the National Board of

Health, Siltasaarenkatu 18 A , 00530 Helsinki 53 (Finland). His clinical specialization is in sero-
bacteriology, dermatology and pulmonary diseases and he has been Chief National Officer for
Tuberculosis and Chief of the Statistical Department. He has published numerous articles on
epidemiology, health policy and planning.

Int. Soc. Sei. J., Vol. X X I X , N o . 3, 1977

420 A. S. Hr

Health service information systems, as they n o w exist, are often ineffective and inefficient
despite the clear need for them Health information systems need to be designed once
again, starting from basic principles.

This is so because casual impressions and 'rules of thumb' can help in orientation
and m a y even represent the only possibility in some cases, but the effective delivery
of services needs constant monitoring based on reliable measurements.

Value of information

Great gaps in knowledge can be compensated by determined action and political

will. But the decisions which guide the action will only be as good as the information
upon which they are based. A prerequisite of efficient management is a reasonable
amount of information concerning problems, resources, possibilities of intervention
and the 'environment' of specific actions.
There is not, and hardly ever has been, any disagreement in principle about
the value of knowledge as one of the foundations for meaningful action. But if the
content of information or knowledge is to be described in detail, then opinions differ.
S o m e administrators reject nearly all quantifiable information like statistics,
research findings, etc., on the argument that these are matters where great invest-
ments give very limited returns. Their case is usually based on irrelevance, delay,
unreadability or related matters, the following statement in a World Health Organ-
ization ( W H O ) report being indicative: 'At present the statistical toolboxes of m a n y
health administrators are cluttered up with useless tools which obscure rather than
reveal essential facts' ( W H O , 1967). This was actually written ten years ago, but still
describes widespread attitudes.
It is clear that deliberate observations, generally speaking, are intended to
serve some definable purpose. The information produced is either solely measured
against what is already k n o w n or else assessed in terms of h o w it can be used in
everyday life. T h e former, which allows conclusions to be drawn, is typical of
scientists but not limited to them. It is sometimes said to represent the 'curiosity'
value of information. In everyday life information is, on the other hand, needed to
act or not to act; in other words, to m a k e decisions, which therefore represents its
'decision value'. Ideal information should possess high value in at least one of these
respects. But in reality w e are mainly living under circumstances in which available
information has low value in both respects.
Obviously it is hardly ever possible to maximize both these qualities simul-
taneously. There m a y be exceptions but generally the two values should be kept
separate or at least the difference between them recalled w h e n information needs
are discussed. Information which serves administrative or managerial purposes
rarely adds anything to knowledge concerning the 'natural history' of a disease
 Strengthening health information services 421

or health problem, the focus of interest of clinical and epidemiological research.

Information for pragmatic purposes is therefore to be collected primarily for its
value in decision-making. Since such information has a low 'curiosity value' it
should at least have high 'decision value'. N o objective basis exists on which to
decide which value should have priority; a given situation and expected use alone
dictate which is to be preferred.
W e d o not propose here to devote m u c h further attention to the scientific
aspects of information. Suffice it to say that it is often claimed to be completely
independent of practical considerations so that all planning and guidance are
meaningless. While this m a y be true o n rare occasions, in most cases even such
medical research as is labelled 'basic' or theoretical produces information which also
has at least potential value in decisions.

Decision-making depends on information

The term 'decision' is a very abstract concept; to approach real-life situations it is

appropriate to identify decision-makers m o r e closely. Generally, decisions are taken
in situations where, on the basis of evaluative considerations, certain alternative
ways of behaving are selected. Doing nothing or 'no change' is also a decision:
evaluative considerations indicate that there is no need to act or to change, using
both conceptsdecision-making and evaluationin their widest possible sense.
Evaluation is performed if something that has been observed or assumed is measured
against something which serves as a n o r m . Evaluation sometimesand quite
correctlyconsists of comparisons between different impressions. But, relying
solely on impressions, opinions and 'soft' information cannot be the correct way to
evaluate situations for which quantitative measurements are possible.
It is hardly meaningful to construct any kind of taxonomy of decisions serving
health and health-related aspects, nor is an analysis aiming to show what is actually
required for different types of decisions practical. O n e c o m m o n misconception
should, however, be dispelled. Very often only formal decisions are considered w h e n
information needs are considered. Yet, in s o m e sense, everybody influences societal
decisions m o r e or less directly. Having n o opinion prevents active participation, and
no participation gives greater freedom to others to act. Every citizen has the right to
be properly informed. A n d facts concerning the needs, action possibilities and
resources of society should in principle be available to all interested groups, not
solely to designated decision-makers, w h o often merely endorse what has collectively
been agreed u p o n as correct.
O n e special type of evaluation calls for attention. That the effects of decisions
should be evaluated is a trivial truism k n o w n to everybody, if not always carried
out, but too little attention is given to the evaluation of the methods used w h e n a
decision w a s taken. Relevant elements include what information w a s critical,
422 A. S. Hr

what was missing, what could have been omitted without altering the results, etc.
Very often, the past is the past and n o comparable situation will ever recur.
O n numerous if not on most occasions, decisions are actually taken step by step in
order to control or keep an absolute or relative balance within a system, especially
since it is hardly possible to adopt any other procedure where future decisions and
their critical information needs are concerned. O n e m a y summarize by saying that
decision-makers translate information into instructions to the system or to organ-
izations. Such information as makes evaluative procedures possible is relevant.

Determining information content

Planning can theoretically be applied to anything where intentional action is

considered possible. Usually it is undertaken through the outcomes of decisions but
it is not illogical to plan services for planning itself, such as ways of collecting
information.
In principle two different aspects of information services can be considered
in this connection, according to whether content of information is the focus of
interest, or attention is directed more to the methodological aspects of information
collection, processing and presentation. In real-life situations both aspects are
important but there is reason to discuss them separately here.
First, information content. There are numerous and widespread misconcep-
tions concerning information intended to serve decision. O n e of these is the belief
that it is easy to k n o w what is needed. Textbooks on epidemiology or medical
statistics devote hardly any attention to this problem. Presentations mainly concen-
trate on analytical techniques applicable to existing data but not on the needs which
communities might have in relation to information. In reality it is very difficult to
show objectively what information is needed or has great decision value. Needs
vary as between decision-makers and are directly related to situations and changes
in environmental conditions which cannot be predicted.
Another c o m m o n but mistaken tradition is to place the entire responsibility
for information production on technical experts, such as statisticians. While perhaps
justifiable on methodological grounds, it cannot be extended to the content of
information. T h e best planners of information content are responsible decision-
makers ( N O M E S K O , 1973).
All decisions are based upon some sort of simplified picture of reality, hence
customary allusions to 'models'. Constituent parts of a model m a y be measurable
aspects of real life but also concepts, values and various impressions. Such 'mental
models', which cannot be fully described and definitely not formalized, are actually
used in politics, and generally w h e n very different qualities and aspects of matters
are to be taken into account. O n e m a y claim that if any hierarchy of models exists,
sound 'mental models' occupy the highest position because they need understanding,
 Strengthening health information services 423

balance of values, experience and often even intuition. There are also dichotomies
which can be applied to models. They are either formal or informal. Formal models
can be either quantified or not. Relatively, mathematical models (simulation,
deterministic, analogic) rank lowest, since the more comprehensive or strategic the
problems, the more the solutions are based on mental models. Health policy
decisions are compromises between interest groups or their representatives with
different mental models. Mathematical models usually best serve tactical or
especially technical decisions.
O n e of the general benefits of planning is that, in order to open up alternative
ways of behaving, an inventory of models becomes indispensable. Very often these
models are not m a d e explicit but in any case the planning process indicates what
should be k n o w n ; in other words, what should be the content of information. But
models can be constructed solely to serve information service planning. There is also
information such as statistical series which is based on simple and generally k n o w n
interrelationships and hardly deserves to be called a model at all.
The word 'system' is unavoidable in this context and it is hardly possible to
discuss models without reference to it. In this connection 'system' does not refer to
well organized, methodical, hierarchial structures but is a term for a group of parts
or objects interacting for a purpose,
The components of a system can be concepts (like health), ideas (e.g. equity),
objects (e.g. hospitals) and persons (e.g. physicians). Together they form a whole in
which all components interact, either supporting or controlling each other. T h e
element that makes interaction possible is information, understood in its widest
possible sense. The components of a system again are systems (subsystems) and any
system is a part of a greater one, usually even of m a n y .
O n e of the positive features of the system concept is that it makes it very
natural to cross sectoral boundaries and both formal and informal components can
be covered. If a systems approach is applied to modern management, which operates
with the whole in mind, this can be called 'systems management' (Johnson et al,
1973): management aims to guide the system as a whole in a planned direction. O n
the other hand, management itself can be seen as a system, partly formal (admin-
istration), partly informal (pressure groups, such as voluntary associations), and its
main products are instructions on h o w the subsystem should behave. The essential
elements in management are decisions, which are in fact mainly instructions based
on information of different kinds. 'Information system' is the generic term for all
such activities as ensure that management has relevant information w h e n making
decisions. N o t only quantitative or qualitative parameters are required: in reality,
management is also based on value judgements, intuitive predictions, subjective
experiences, etc., though in practice an 'information production system' is usually
defined more narrowly (Alderson, 1974).
The construction of models is a logicalfirststep in planning information
content, but is not always simple. O n e reason is the different types of personality
424 A. S. Hr

a m o n g decision-makers: active and emotionally strongly motivated persons are not

very fond of measurements not directly helpful and which concentrate on less central
aspects. A n experienced bureaucrat does not feel any temptation to collect data
concerning matters he has not dealt with in the past. A manager without m u c h
experience displays general 'curiosity'. A n d there are always some w h o compensate
by overdoing research, tabulated data, etc.
Difficulties related to the fact that the life of organizationsfluctuatesare
unavoidable. During quiet periods, without major managerial problems, infor-
mation needs are minimal. But there are also critical situations, in which organ-
izational survival is directly related to appropriate information. Measurements are
needed of aspects which are hardly relevant at all during quiet periods. A n active,
young organization requires a lot of not particularly standardized information; an
older, conservative one is satisfied with a few data conforming to exactly stan-
dardized norms.
Models are consequently not an objective in themselves but only a means
to help in the real problem of h o w to ascertain information needs. The focus of
interest is not the formulation of decisions to be agreed upon, but only the infor-
mation items or indicators needed to form opinions concerning a given problem,
for which limited purpose relatively crude models are serviceable. But even they can
only be constructed by those w h o k n o w the problem, mostly requiring teamwork by
experts. Valid models cannot be constructed by those w h o have no opportunity to
analyse in depth, such as an expert in statistical methodology.

Methodological aspects of information systems

In principle, a Health Information System (HIS) is a service system primarily

oriented to the decision-making process, it being perhaps more correct to refer to
this as Health Information Services (Bedenham et al., 1972). The n a m e is not its
most important aspect, but systems must involve m u c h more than classical statistics:
it is not meaningful to discuss content without considering methodological aspects
(Hr, 1972).
O n e natural component of a Health Information System is individual
data (I-D) commonly stored in data banks (data-archives, registers, etc.). A n infor-
mation system which is intended to serve a variety of planning activities and
decision situations in an organizational unit obviously tends to be based on one or
more such components, storing information on cases, events, persons, etc. The basic
idea is to m a k e it possible to process collected data in such a w a y that it can be
recast to suit any tabulation or representation required. In practice, most I - D systems
rely on electronic data-processing technology which gives some leeway for the
planning of information content. Variables which are difficult to handle in tra-
ditional reports can be included, which to some extent makes the work of primary
 Strengthening health information services 425

informants less taxing. In theory it is possible to construct data banks which are
fairly comprehensive but in practice, in the healthfield,limited, problem-oriented
data banks, which can be linked w h e n need arises, are more useful ( W H O , 1976,
Techn. Rep. 587).
The central element of the traditional statistical system, or 'routine statistics',
is a questionnaire or form which summarizes the work done by basic informants,
normally over a defined period. National figures are aggregates of lower-level
summaries. Such an approach has s o m e obviously positive aspects: direct costs are
relatively low and not very m u c h expertise is required. Relatively long time-series
are usually available. However, such systems are rigid and cannot provide answers
to differently formulated questions. A great deal of information is lost when the
basic data are agglomerated, which limits the value of a system especially in planning
and active management. There are sectors which such a system serves quite well; in
otherfieldsagain the value of statistics in the traditional sense is very limited indeed.
O n e basic requirement of proper information both for management and for
more general descriptive purposes is integration or linkage of data. This can be
achieved only by systematically applying c o m m o n classifications and uniform
definitions in all relevant subsystems. In theory such requirements can easily be
filled but in practice only very limited options are feasible. Codes which satisfy the
specific needs of very different societal sectors escalate to impracticability. Personal
linkage is not always favoured by citizens and the systematic use of personal
identification is possible only after a rather long lead period even in a developed
country ( N O M E S K O , 1973). A more reasonable solution consists of special sample
surveys which cross the sectoral boundaries of societal systems and link very
different types of information to an individual respondent or family; for example the
health situation and different factors concerning past and present environment, both
physical and social, can be linked and analysed.
A single ad hoc survey is, in principle, a situational analysis of current
circumstances, but in m a n y decisions trends are m o r e important than thefigures.A
natural solution is to repeat surveys. T h e problems themselves dictate whether the
identical set or another comparable sample of basic informants or objects of
measurement is to be studied. A before/after strategy is well suited to situations
where n e w legislation, intense innovation, a marked increase of resources or some
other unique event can serve as a dividing line. In some countries such surveys are
undertaken as components of the national health information system (Purola
et al., 1974). A further component of an information system is experts, both
scientific ones and persons w h o k n o w the facts and the situation. O n e can further
include literature as a source of information and part of an information system.
In planning a H I S the objective is to provide information which corresponds
to the needs of users (the decision-makers in the broad sense), but which is also
well-founded and economic from a m o r e technical point of view. In practice this
requires a dialogue between information producers and information users. Statistical
426 A. S. Hr

experts are obvious m e m b e r s of teams to analyse decisions, but if continuous

changes in environment, activities and interests occur, the dialogue must be a
continuous process, which can hardly arise if there is n o close association with the
organization and its management system. A t a strategic level very careful consider-
ation deserves to be given to the correct organizational location of information
services. Being a part of the general statistical services for the nation makes it, to
some extent, easier to cross traditional sectoral boundaries in society and collect
more comprehensive information. O n e could also expect such information to be
more impartial and objective (Linder, 1976). But without special arrangements
external evaluators cannot fully participate in the life of an organization: real
problems, preliminary plans, difficulties in communication between different auth-
orities, sudden changes in policy, etc., are not customarily discussed with outsiders.
If information services are formally part of a system it is easier to function as
an internal evaluator, closer relationships and continuous dialogue being clearly
facilitated. Yet there is n o guarantee that published information, at least, is not
biased to serve apologetic purposes. Attention must also be paid to proper location
in the hierarchy, the tradition being to locate a statistical unit rather low d o w n .
This m a y be correct if its responsibilities are limited to routine types of data collection
and processing, but if the aim is really to serve decision-makers, a higher hierarchial
status is preferable. Formal planning automatically focuses attention on the content
of information and it is therefore very natural to run it in close interrelationship with
information. In the Scandinavian countries, for example, there is a tendency for
health statistics to be part of the planning department of the national health
administration. In Sweden, health statistics are located in a special office of the
Planning Department, while in Finland they are completely integrated with the
Department of Planning.

Health information for general purposes

W e n o w turn to an analysis of real situations divided into two parts. This section
will be devoted to international and national activities not strictly oriented to
health problems but intended rather to serve general purposes and policy formation
at different levels of social life. In the next section the focus is at the micro-level of
those information services which more directly serve health and related service
purposes.
Both at international and national levels m u c h time and effort have been
devoted to two major types of project: the development of statistical systems for the
description of social, demographic, and environmental phenomena and the closely
related attempts to construct indicators to monitor important areas of social
interest (Hr, 1976).
International organizations are naturally interested in information which
 Strengthening health information services 427

contributes to a global view of problems. In principle, all nations have the same
interests, as represented by those advanced countries whose standards can serve as
general norms. But at the global scale m a n y matters are too trivial for some countries
and entirely beyond the capacity of numerous others. Internationally comparable
figures, suitable as guidance for international organizations, are only exceptionally
useful at the national level.
O n e of the reasons sometimes preventing the publication of data is fear of
being misunderstood and misjudged by those w h o d o not k n o w the real background.
O n the basis of relatively superficial analyses of suicide statistics, for example, some
societies have been labelled 'decadent'. Abortion statistics have been used as inter-
nationally valid indicators of sexual laxity. Variously formulated definitions of
deaths due to accidents have lifted some nations to undeserved pinnacles on this
count. In none of these cases has d a m a g e been irreparable, but within the family of
nations the esteem of others is at least as important as in h u m a n families. A n d one
m a y add that biased analyses or comparisons can be extremely powerful a m m u -
nition in national politics, for instance during elections. It should also be kept in
mind that specific data collection and processing is laborious and requires time and
effort by key personnel, which in most cases has a full work-load. Governments are
not always too generous in such situations.
Such difficulties reflect the basic problem, at present unsolvable: that nations
understand the purposes for which information is needed in order to be properly
motivated. In terms of our earlier argument a generally understood or at least
accepted 'mental model' should exist. Information from different national sources
should be relevant in evaluation on the basis of this model. Formal consensus does
exist at a very abstract conceptual level but not on any more practicable one. T h e
World Health Organization's definition of'health', for instance, is m u c h too broad
and abstract. In thefieldof infectious diseases a consensus concerning the role of
international agencies exists and the statistics are accordingly the most complete.
There is also some kind of shared ideal about the goals and objectives of social
policy but n o m o r e solid, generally accepted models serving international purposes.
In this value-loaded area it is especially difficult to m a k e any binding agreements or
achieve a consensus of priorities. A t the national level, in most countries, the same
types of difficulty crop u p .
T h e objective of the major international projects mentioned is to co-ordinate
and develop existing statistical subsystems into a comprehensive whole that would
cover all relevant problem areas in society. Emphasis is, therefore, m o r e on principles
of construction and a view from above is typical. A s one might expect, very little
attention is paid to end use and users in such projects. A recent United Nations
document states that

except for instrumental use the system is intended to help in improving our knowledge of
social systems and in working out better social policies. Thefirstkind of use envisaged,
428 A. S. Hr

therefore, is in connection with policy formation which should be based on the best
knowledge available. The second kind of use envisaged is in connection with the research
needed to enlarge our understanding of social processes thus providing a firmer basis
for social policies (United Nations, 1975).

The Statistical System for National Accounts ( S N A ) is the best practical example
because it functions, a great number of countries provide comparable data and it
produces valuable indexes of the national economy ( G N P , etc.). The comparable
System of Social and Demographic Statistics (SSDS) should in principle do as m u c h .
Originated under United Nations auspices, m a n y international agencies such as
the Economic Commission for Europe ( E C E ) and the World Health Organization
as well as national statistical authorities have actively participated. In principle the
interest aroused by this project has been considerable in numerous countries. T h e
basic documents strongly emphasized the idea that the life of an individual, as well
as of the population as a whole, passes through successive states or sequences,
e.g. childhood, primary education, military service, and vocationally active life.
Statistics are to be set out in matrices showing the flow and stocks at the beginning
and end of each sequence. In the healthfield,age and, generally speaking, time is a
relevant variable, especially in epidemiological problems. Stone (1970), the author
of thefirstdrafts, proposed that the series o n the state of health and, on the other
hand, deaths should be aggregated into a few indicators of years of healthy life and
of restricted activity, which is ambitious and difficult to carry out. It is also obvious
that lack of a c o m m o n base unit, like m o n e y in economic statistics, complicates the
construction of integrated accounts. T h e system has numerous quite traditional
subsystems and recent efforts have been directed to definitions and classifications to
enhance linkage and comparability. Another quite realistic goal is to provide
guidelines for national specialists on h o w to develop socio-demographic statistics
which can be linked and co-ordinated and cover all important aspects. A t the
present stage each country can accept such parts of the system as are of interest to it.
Health is one of the components of the system, but it is obvious that, on the
basis of present knowledge, health accounts cannot be presented in a single or
limited number of categories. T h e objective of full coverage is not unreasonable
while co-ordination and linkage potential are also very appropriate requirements
for any well organized Health Information System. T h e real difficulties are related
to the use of personal identification which, even within health service systems,
cannot be used freely in most countries, which makes it all the more difficult to link
with other sectors on this basis. This problem arouses so m u c h friction that its
advantages can well be questioned. In any case, it is only reasonable to keep in mind
that linkage or, more correctly, integration, can be achieved at various levels of
aggregation and in different ways. N u m e r o u s characteristics or units are potentially
useful for aggregative purposes, such as location, e.g. a local authority area,
occupation or income level. Another good example is the use of comparable diag-
 Strengthening health information services 429

nostic classifications wherever illnesses or disease are recorded. In practice, different

users m a y require specifically modified classifications, but the different versions
should have enough in c o m m o n for comparisons to be possible. Despite the well-
k n o w n limitations of the present International Classification of Diseases, it is in
nation-wide use in Finland, to give just one example. In hospitals afive-digitm o d i -
fication is used, for mortality statistics a three-digit one, for health and social
insurance, three digits, and in primary health services a provisional list of 120 selected
numbers has been in provisional use.
Mention must also be m a d e of widespread national and international efforts
to construct sets of social indicators to picture, as succinctly as possible, the social
condition of a nation. Again economic indicators are prominent because it can be
assumed that they are correlated with most of the positively valued societal norms.
In a recent issue of this Journal, L a n d (1975) thoroughly discussed the present
situation. Interest in social indicators has a history of about fifteen years but
progress has not been great. Even the definition of an indicator can still be discussed:
Land proposes: ' . . . social indicators are statistics which measure social conditions
and changes therein over time for various segments of a population'. B y 'social
condition' is meant both the external (social and physical) and the internal (subjective
and perceptive) contexts of h u m a n existence in a given society.
If the word 'statistics' is taken in the broad sense this definition is sufficiently
flexible and easily applicable to health-related information. But such general indexes
in the healthfieldas are available at present are inaccurate, even misleading. T h e
situation has recently been summarized in the World Health Statistics Report (1976)
as follows:

F r o m the research developed so far, some important points about health measurement
have been learned. It is n o w generally recognized that (1) health is a complex variable;
(2) a single index such as the gross national product is inadequate (rather, indexes need to be
developed to suit the purposes for which they are intended to be used); and (3) indexes
developed for the same purpose should be standardized to permit international
comparisons.

T h e second point merits special attention. Without a guiding model the use of
information is uncertain. T h e difficulty lies in the lack of consensus on what should
be done, what is valid and which is the order of priorities, most obviously at the
international level but by n o means to be underrated at national levels either.

Information for health services

Since health problems can reflect environmental and social circumstances, which
cannot be resolved by traditional health care, the m i n i m u m requirement and logical
first step is that such interrelationships should be recognized and measured.
430 A. S. Hr

Research is needed in order to establish possible causes and effects, while hypotheses,
in other words models of the 'natural history of the problem', should be set u p to
show what interventions can be considered.
In reality, health services are mainly geared to problems which, while not quite
u n k n o w n are also probably not completely understood. In any case a purposeful and
well organized Health Information System cannot begin from a complete range of
possibly interesting information categories. There are n o limits to such a range and
the most relevant items can easily be missing. It is hardly possible to construct a
system which has no weaknesses at all but w e m a y c o m e closest to this ideal by
analyzing services, programmes, projects, activities, etc., so as to ascertain real goals
and alternatives to be considered. Another objective is to locate what decisions need
to be taken and what information should be available to anybody faced with deciding.

Concluding remarks

Each organization, or m o r e broadly, each system has its o w n specific habits and
traditions in making decisions, reflected in its formal procedures but specially in
evaluative and planning activities, and naturally also in information services. O n e
can therefore postulate that an ideal information system is specific to each health
service system and organization. It is also evident that n o ready-made blueprints
exist, which national authorities could adopt in search of improvements. Something
can always be copied or taken over from other systems, but in principle every
responsible authority must plan and construct its o w n information services. A n
active health policy is indeed reflected by active information services.
O n the other hand, health has numerous aspects which are definitely inter-
national. The basic natural histories of infectious diseases for instance are the same
everywhere, as to a marked extent are also other cause-effect relationships related to
health and diseases. A s a result, a great m a n y of the results of scientific research in the
medicalfieldare internationally valid and potentially applicable everywhere. There
are also m a n y c o m m o n elements in health-related activities and programmes, as
reflected in information services like statistics.
The key problem in developing information services which are really to serve
their purpose is to answer the question: W h a t should be k n o w n ? T o o little emphasis
has been given to laying responsibility for information content primarily on decision-
makers, not on statisticians and data processers. Thus statistics and generally
quantitative information tend to be undervalued and there is no very close
co-operation between bureaucrats and researchers, especially theoretically oriented
ones. The lack of a c o m m o n 'language' makes these difficulties even greater.
Furthermore, active dialogue between producers of statistical-type infor-
mation and the expected users is exceptional; its complete absence is perhaps m o r e
c o m m o n . O n e reason is that the present generation of senior decision-makers has
 Strengthening health information services 431

not been educated in the use of quantitative information, while academic training in
statistics stresses technical aspects, neglecting to demonstrate h o w to usefindingsin
collective decisions. A s a result statisticians are not always interested in the same
aspects of a problem as decision-makers: they produce reports which are too dense
to read and are not correctly timed.
Another misconception perhaps typical of information producers is their
belief that in order to k n o w what decision-makers need it suffices to ask them a few
questions. For more technical problems this might w o r k but it definitely cannot be
adequate for strategic, policy-level problems, where mental models are relevant. T o
be able to analyse and describe health programmes and the activities of an organ-
ization so thoroughly that real goals are m a d e explicit, is complex and difficult. Still
more difficult is it to obtain a motivated consensus on critical information to be
collected. A team of varied specializations with a strong representation of m a n a -
gerial and other experts w h o thoroughly understand problems is a natural solution.
Such a team should simulate possible situations and alternative actions with infor-
mation needs specially in mind, which can correctly go under the n a m e of planning.
It is actually a very useful exercise and establishes the idea that information services
can and must be planned deliberately. A trend which needs critical scrutiny is that of
establishing statistics, research and registers serving specific purposes separately.
All produce useful but one-sided information, and if not properly co-ordinated
decisions m a y still be m a d e under conditions where either too m u c h detailed infor-
mation prevents its practical use, or n o information is available about minor but
operationally relevant matters.
Health information systems are generally not undeveloped by comparison
with statistics in numerous other social services. Very great complexity characterizes
them, but attempts to construct a comprehensive health information system and
derive a limited number of valid indicators are perfectly acceptable goals. Problems
arise more in the great unexplored areas, as for instance between childhood experi-
ences and health problems in later life, or in relation to working conditions and
other environmental cause-effect relationships. Difficult enough in relation to
physical health, things become even m o r e so if mental health, and especially the
interaction between these spheres, is broached. In this area very little indeed is
k n o w n , m u c h basic research being needed before the theoretical foundations m a k e
further progress possible.
In the healthfieldthere are but rare occasions on which one can objectively
demonstrate the real returns to given efforts. M u c h can, however, be said in favour
of the conclusion that very few relatively small inputs can give such valuable returns
as the development of information services.
 432
References
A L D E R S O N , M . R . 1974. Health Information System.
WHO Chronicle, Vol. 28, N o . 52.
BoDENHAM, K . E . ; W E L L M A N , F . 1972. Foundations
for Health Service Management. London,
Oxford University Press. 103 p. (Occasional
Hundreds 3.)
H R , A . S. 1972. Planning Information Systems for
Health Services. Meth. Inf. Med., Vol. 11,
N o . 1.
. 1976. Strategies for the Development of
Health-Related Statistics. In: Pflanz/Schach
(ed.), Cross-National Sociomedical Research.
Concepts-Methods-Practice. Thieme.
JOHNSON, R. A.; KAST, F. E.; ROSENZWEIG, J. E.
1973. The Theory and Management of Systems.
3rd ed. McGraw-Hill Kogakusha, Ltd. 539 p.
L A N D , K . C . 1975. Theories, Models and Indicators
of Social Change. Int. Soc. Sei. J. Vol. XXVII,
N o . l,p. 7.
L I N D E R , F. R . 1976. Recent Trends in Health Stat-
istics. WHO Chronicle, Vol. 30, N o . 58.
N E U H A U S E R , D . 1976. The Really Effective Health
Delivery System. Health Care Management,
Vol. 1, N o . 25.
N O M E S K O . 1973. Planning Information Services for
Health Administration. Decision Simulation
Approach. Stockholm. 35 p. (Mimeo.)
A. S. Hr
P U R O L A , T . ; K A L I M O , E . ; N Y M A N , K . 1974. Health
Services Use and Health Status under National
Sickness Insurance. Helsinki. 317 p. (Publ. of
Soc. Ins. Inst. Finland. A:l 1/1974.)
S T O N E , R . 1970. Health and Medical Care in the
Social Accounts, Demographic and Economic.
(Conf. Eur. Stats./WG. 36/4; W H O / E U R O
4913.4.)
U N I T E D N A T I O N S D E P T . O F E C O N O M I C A N D SOCIAL
A F F A I R S . S T A T . O F F I C E . 1975. Towards a Sys-
tem of Social and Demographic Statistics.
Studies in Methodology. (Series F N o . 18.
U N . ) , 187 p.
The Efficiency of Medical Care. 1967. Copenhagen.
( W H O / E U R O 294.2.)
W H O . 1973. Organizational Study on Methods o
Promoting the Development of Basic Health
Services. Geneva. ( W H O Off. Records
N o . 206.)
. 1976. Objectives and Organization of the Clear-
inghouse for Health Indexes in the National
Center for Health Statistics, United States
of America. W . H . Stat. Rep. Vol. 29,
N o . 140.
. 1976. Statistical Indices of Family Health
Geneva, 92 p. ( W H O Techn. Rep. Ser. 587.)
 T h e search for health indicators*

Emile Levy

The need for health indicators

For some years n o w , all industrial societies have been actively interested in the
problem of establishing a set of social indicators to act as indicators of welfare, and
all the international organizations (the United Nations, O E C D , the European
Communities, etc.) are giving vigorous encouragement to this work. Research into
social indicators, however, always includes the subject of health. The reason for this
is that although the list of social preoccupations can vary to some extent, depending
on the period and the country, concern for health is a constant which no one dreams
of questioning. It can even be said that health indicators are frequently taken as the
best example of social indicators.
T w o reasons at least can be put forward to explain this situation. Firstly, the
field of health has the obvious advantage of being based on a specific system for
the provision and distribution of medical care. Secondly, data concerning life
expectancy at birth, and to a lesser degree, mortality rates (in particular infant
mortality) have long been considered as assuming the status of composite
'indicators' of a population's state of health.
The situation in thisfieldis nevertheless m u c h less favourable than one might
imagine. Indeed, it is quite clear that mortality data in industrial societies fall
far short of expressing health phenomena as a whole, particularly since gains in life
expectancy are n o w insignificant, not to say non-existent, and certain forms of
morbidity (of the chronic degenerative type) are looming increasingly large.

After holding various teaching appointments at the Universities of Tunis, Caen and Paris X, Pro-
fessor Emile Levy is now attached to the Universit de Paris-Dauphine, Place du Marchal-
de-Lattre-de-Tassigny, 75775 Paris Cedex 16. In 1966, he created the section for 'studies and pro-
spectives' of the French Ministry of Social Affairs and presided over the commission which prepared
a report, 'Reflections on the Future of the Health System', as well as over another commission
on the economics of medicine and medical studies. He is the author of Analyse Structurale et
Mthodologie conomique and (with M . Bungener, G. Dumenil and F. Fagnani) of L'conomie
du Systme de Sant and is preparing works on hospital management and on evaluating the costs
of illness.
* This article is based on a study 'Indicateurs de
Sant et Analyse du Systme Franais' car-
ried out in 1972 for the French Commissariat
du Plan by Emile Levy in collaboration with
Martine Bungener, Grard Dumenil and
Francis Fagnani.
Int. Soc. Sei. J., Vol. X X I X , N o . 3, 1977
434 Emile Levy

Again, the relationship between the state of health and the system for the
provision and distribution of medical care remains unclear, and the 'output' of
the system remains ill-defined in terms of final results. A certain amount of
confusion thus prevails with regard to the indicators used by planners, which, in
addition to those referred to above, include a miscellany such as the number of
doctors per inhabitant, the number of hospital beds per inhabitant, per capita
consumption of medical benefits, etc.
The need to have satisfactory indicators of the state of health of the French
people was stated yet again in a question put by the French Minister of Health
to a working party set up by him in 1972 to consider decision-making in thefieldof
health:

. . . if it is true, as argued in certain American studies, that in over-developed countries the

considerable increase in the consumption of medical benefits (hence in expenditure) would
seem to produce no noticeable improvement in public health, we are then genuinely
justified in asking why there is at the present time such an escalation of needs, both as
regards the national provision of staff and equipment for the health service, and as regards
consumption.

There is n o doubt that, before making any attempt to analyse this problem, one
must k n o w whether the basic indicators usedin particular mortality indi-
catorscorrectly reflect the state of health.

Health indicators or health-status indicators?

T h e terms used to describe what w e are investigating are ambiguous. A t times it

seems quite clear that w e are trying to describe the real 'state' of health of a popu-
lation, in terms of thefinalresult and irrespective of the factors which determine it
or explain it. A t other times, it seems that the chief aim is to single out indicators
of the effectiveness of the system for the provision and distribution of medical care.
Finally, it would sometimes seem that any quantitative data connected with health,
whether physical orfinancialdata, m a y be considered as health indicators in the
broad, general sense of the term.
In thefirstcase the indicators reflect health status, and in the second they
are indicators of h o w the health system operates.
If, placed with these alternatives, w e can state that our major concern should
be with health-status indicators, one of our main methodological assumptions will
be that w e cannot afford to neglect the system indicators inasmuch as they m a y
throw light on the health-status indicators.
 The search for health indicators 435

Who needs health indicators?

There are at least three interested groupspublic opinion, administrators and

planners, and doctorswhose requirements d o not all coincide.
It has been argued1 that a simple, clear composite indicator needs to be
found to satisfy public opinion and the needs of political debate. It is true that health
is a particularly thorny subject, and that the statistics usually advanced in the press
or by politicians are numerous and confused, and difficult for the average citizen to
interpret.
It is also true that administrators and planners need indicators which will
go beyond a mere 'instrument panel' from which developments in the population's
state of health can be monitored. For this group, the useful indicators are those
which enable them to set health in its social context, identify the impact of the
health service, clarify options and ultimately m o v e health planning past the stage
of medical and hospital facilities.
A s for doctors, their chief need is for indicators measuring the effectiveness
of their action. This means that the scale of the analysis must also vary since doctors
need to be able to measure the effectiveness of their work both at the level of
specific cases of treatment and in order to clarify choices between alternative forms
of treatment for a given illness. Hence what is required are indicators of a m u c h
more refined sort than those devised for planners.
However, the fact that different kinds of indicators are needed does not entitle
us to deduce that the problem of constructing a composite health-status indicator is
of no interest to the planner or to the medical profession or to deduce that overall
indicators and specific indicators should be entirely independent of each other. O n
the contrary, it would be more satisfactory for them to be interconnected, even if the
idea of such an interconnection is very difficult to conceive.

Why should we have health indicators?

It is not easy to single out the objectives being aimed at in the search for health
indicators.
The objective m a y be the apparently modest one of seeking knowledge of a
past and/or present situation. This is the case w h e n , as in a United States document, 2
questions are raised such as: what stage have w e reached as regards the population's
state of health? This objective makes it possible to ask whether life expectancy,
mortality rates, morbidity rates, etc., correctly reflect the phenomenon being studied,
both as a whole and as it develops. This is the 'instrument panel' approach to
which w e have already referred, and which is naturally accompanied by the desire
to adopt values which will act as 'warning lights'.
A somewhat higher level of requirement, the aim m a y be to establish
indicators which would m a k e it possible not only to note a situation or to monitor
436 Emile Levy

trends, but also to understand the reasons or factors involved and to gauge their
respective impact. This already presupposes a more detailed attempt at analysis
in order to untangle the complex w e b of interrelations existing between these
factors.
Lastly, the most ambitious target is that of seeking a system of indicators to be
used as a basis for decision-making, e.g. a simulation model which would m a k e it
possible to foresee the implications, for a population's state of health, of a decision
or set of measures envisaged.
It should be admitted, however, that it is unrealistic to set one's sights so
high in thefieldof health economics. T h e fact is that sectors in which a sufficient
quantity of information is available (for example epidemiology) and where
knowledge about interrelationships is adequate enough to establish such models,
are relatively few and far between. Only in the case of a few diseases d o w e k n o w
their natural history and the efficacy of the various techniques for diagnosis, possible
treatment and prevention, and it is to be feared that it will be a long time before w e
are able to extend this type of study to the full range of phenomena relating to
health and sickness.
Nevertheless there is a great temptation to aim at an integrated set of
indicators which would be of value simultaneously for descriptive, explanatory,
forward planning and decision-making purposes, and all these objectives are
indeed linked. F r o m an operational point of view, however, it still remains
necessary to draw a distinction between them, since otherwise there is a risk of failing
to achieve any of them. Even from just the planner's point of view which w e have
chosen to adopt here, the myth of a 'maid-of-all-work' system of health indicators
seems both dangerous and inappropriate. T h e indicators which would be of use for
determining objectives or priorities, formulating programmes of action (hence
checking whether the means correspond to the ends) orfinallyassessing the result
of these actions, would not all be the same. Considerations of the economic and
social cost of illness, and financial indicators in particular, do not intervene in the
same way at each of these levels.

How are we to obtain health indicators?

In any search for social indicators one always comes across two types of approach.
There is the empirical and statistical approach from below, which consists of
starting from existing information, examining it in great detail in the light of
established criteria,3 and selecting the data which have the degree of significance
desired to express, directly or indirectly, a population's state of health. There is
also the approach from above, which begins by defining the phenomenon to be
measured (for example a scale of states of health), investigates what kind of
information is needed and, if any gaps are noted, recommends the introduction of
systems for collecting further information.
 The search for health indicators 437

With thefirstapproach, which relates to a short-term operational viewpoint,

all that is done is to link u p a certain quantity of data, considered as significant,
within an integrated scheme which will be used as a 'cipher key' to interpret a
complex social situation. With the second approach, emphasis is placed from the
outset o n research, and it cannot be expected to result in an integrated system of
quantified information except in the m e d i u m or long term.
In point of fact, these two approaches are always used in conjunction with
each other, and a satisfactory solution will aim at combining them. However, it will
be seen from the studies carried out in recent years that the 'mix' between the two
m a y vary appreciably.
Quantified information concerning health is only converted into 'indicators'
when the questions which are actually under consideration have been accurately
defined. T h e notion of an indicator is always relative, and necessarily stated in
terms of afinalresult, being meaningless except in relation to a specific reference
system and a specific function.

T h e difficulties of elaborating a system

T h efirstkind of difficulty arises as soon as one begins to define the area to be

covered by the social indicator. The vagueness of the concepts which can be used
in the socialfieldmakes any attempt at formulation questionable.
In the second place, once relevant variables have been identified, the quality
of the indicator depends on the correct conversion of these variables into numerical
indices, which is m a d e difficult by the defective nature of the measurements
available.
Several ideas regarding the elaboration of social indicators have accordingly
emerged with a view to finding solutions to these problems.

The difficulty of delimiting the scope of the analysis

T h efirstimpression which emerges from a study of the social sector is that it is

impossible to postulate from the outset any logical arrangement. Researchers have
nevertheless been forced to adopt a systematic approach towards apprehending the
reality of the social situation, dividing it u p into various subgroups which appear to
have a certain homogeneity.
A m o n g these, thefieldof public health is sometimes regarded as one of the
easiest to define, since it is based on a specific system for the provision and
distribution of medical care, the ultimate purpose of which is beyond dispute:
'The purpose of medicine is to prevent and cure illness, alleviate suffering and
prevent the sick from dying.'4
However, it becomes obvious quite quickly that underlying this apparently
438 Emile Levy

straightforward definition is a state of affairs that is very far from clear, and which
varies for each individual and each institution. Health m a y in one case be an
individual state, in another the state of a nation taken as a whole, or a need, aright,
a group of illnesses to be prevented, an aim to be achieved, or a policy objective.
Each of these realities has its corresponding specific concept and its o w n particular
limits. This is w h y , having regard to the general lines of the study and its scope, a
m o r e or less arbitrary decision has to be taken and the limits of thefieldin question
specified.
In theory, the healthfieldshould cover an autonomous system possessing an
internal cohesion of such a kind that the links between thisfieldand the rest of the
social sphere are reduced to a m i n i m u m . O n e m a y restrict one's view of thefieldof
public health to the health service alone or, on the contrary, adopt a comprehensive
viewpoint embracing a large number of aspects such as life-style, housing conditions
or even the level of education, all of which contribute at least indirectly towards
building up a state of health. A n intermediate approach would be to go beyond the
strict notion of illness and to consider, as far as possible, the overall state of the
individual. F r o m this point of view it m a y be necessary to relate the individual to
his social environment and to include in thefieldof study a number of factors
which are regarded as contributory to producing a state of health.
N u m e r o u s interrelations thus exist between the healthfieldand the social
sphere as a whole. T h e form of the machinery for medical care and the w a y it is
used are extensively conditioned by the social structure. Society as a whole
exerts a diffuse but continuing influence on the attitudes to health care of the different
people involved. T h e health system is a developing system. The relative nature of
the notions of health and sickness, and developments in the recognized field of
morbidity and its internal structure are continually bringing about changes in the
healthfield.A n y analysis of thisfieldis thus relative to a certain state of medical
knowledge, and to the extent to which a society is 'medicalized'.
The indicators elaborated will reflect the principle underlying the definition
of thefield.A n y further developments affecting the scope and content of the field
should also entail further adjustments in the indicators proposed.

The problems of quantifying and interpreting the statistical series available

W e shall not revert to the difficulty of quantifying a social system (because of the
absence of norms and units of measurement) but will confine ourselves to stating
here some of the difficulties inherent in expressing health in statistical terms.
The large number of viewpoints and the variety of ideas concerning health
have led to the emergence of two parallel ways of speaking about it. O n the one
hand is a scientific or technical language, which is not even itself homogeneous,
used by public health organizations and those professionally concerned with health.
O n the other hand, health as an individual state is expressed by each person in terms
 The search for health indicators 439

specific to himself. Superficially, these m a y approximate in varying degrees to

the language referred to above, depending o n the medical knowledge of the
person using them. T h e statistics which can be obtained will therefore, depending
on the institution compiling them, be related to one or other of these languages
and give rise to ambiguity as regards the medical terms used and the realities they
reflect.
It should also be stressed here that morbidity data compiled either directly
from the individual or following his encounter with the medical care system, are
only a partial indication of morbidity, since it isfirstnecessary for the individual
concerned to recognize that he is ill, in order to say so and to have recourse to the
health service.
With all quantitative data there is a discrepancy to be taken into account,
although it is difficult to measure, between the values obtained and the actual
situation. The fact nevertheless remains that the problem of interpreting statistics
arises in connection with allfiguresrelating to health. Figures are not meaningful in
themselves, but only in relation to the institution which compiles them. Their
validity is relative to the degree of specialization of that institution, and their
representativity depends on its place within the public health system.
T h e fact is that public health statistics primarily reflect the medical organiz-
ation of a society and its relative efficiency in evaluating the population's health. T h e
interpretation of any variation is a delicate matter since public health statistics
m a y express a change in health status following developments in the methods for
compiling data, or advances in medicine or nosology.
Furthermore, interpretations m a y diverge completely, depending on the
reference system within which these statistics are used. It follows that one and the
same figure m a y express entirely different phenomena, depending on the authority
using it and depending on the degree of importance attached to the various
relationships existing between the fact measured and the rest of the public health
system. A possible example to illustrate this difficulty is the number of hospital
beds per specialization and per head of population. This appears atfirstsight to
reflect regional disparities as regards hospital facilities. It can also, however, for the
purpose of public health planning, be an indicator of the adjustment of the supply
of medical facilities to the needs of the region or country concerned. It m a y be
used as a basis for defining the optimum number of specialists to be trained. If these
hospital beds are considered as having been created in response to a previously
expressed demand, thefigurecan even be used as a morbidity indicator, in default of
m o r e explicit information. Other possible points of view also exist. Each individual
uses thisfigurewith reference to the other data in his possession in order to improve
his o w n knowledge and reach a decision. Figure 1 represents the possible
associations between the four points of view listed above.
Conversely, it is possible to express one and the same p h e n o m e n o n by a
variety of numerical data, each item of which is the expression of a particular facet
 440 Emile Levy

Optimum
number of
medical
specialists

Adjustment of
supply of
facilities to
demand

FIG. 1. Different ways of interpreting a numerical index.

 The search for health indicators 441

of the phenomenon considered. The statistics required to quantify health indicators

should be the subject of a preliminary study in which their exact significance
utilization should be m a d e clear.
Health status has a reality for both the individual and the community. T h e
transition from one to the other by synthesizing and aggregating medical data
substantially reduces the amount of information yielded.
In considering the individual's condition, conclusions are drawn as to the
gravity of the case on the basis of a certain number of features of the person's
illness.
The gravity of a very widespread disease will in view of its social consequences
be assessed in a very different way. There is n o direct method, which is simple and
possesses quantitative equivalence, by which a link between these two extremes can
be established. Passing from the individual to the collective by w a y of a sum-total
of individuals w h o , although suffering from the same illness, m a y be suffering
from it in varying degrees, affords only a very indifferent view of a population's
health status. This calls in question the actual meaning of such aggregations.

The contribution m a d e by a preliminary analysis

of the health system

Whatever form is imparted to the proposed indicators, the analysis used as a basis
for arriving at them should m a k e it possible for the researcher:
N o t to overlook anything essential. If the indicator is m a d e u p of a number of
statistics set side by side, where should one draw the line? W h a t criteria should
be used to choose the number of basic elements, and of statistics to express
them?
In m o r e aggregated indicators, of the type used in the United States, some
dimensions are deliberately left out. Similarly, all multidimensional indi-
cators exclude any reference to suffering or the impact of the medical care
system.
N o t to confuse things. The range of existing indicators does not m a k e it possible to
distinguish between the cure, the stabilization or the non-appearance of an
illness and hence does not m a k e it possible to appraise the different stages of
the intervention of the medical care system.
T o single out the basic links in the chain of causality, since it has been seen above
that, as regards health, the measurement of a variable cannot be divorced
from consideration of the links which connect it with the other elements of the
public health system. It is these links which determine its significance.
It is therefore necessary to shed as m u c h light as possible both on the inter-
relationship of health phenomena and on the operation of the health system. If
w e d o not take the trouble to d o this, our study of the question is likely to remain
442 Emile Levy

entangled in the dilemma referred to above. In particular, this analysis should

provide an opportunity for:
Proposing an operative solution to the problem of delimiting the health field;
Defining the basic concepts, statement of which is an essential prerequisite to the
establishment of indicators;
Collecting the data available and proposing a method of co-ordinating them.
The analysis itself, which concludes with an explanatory diagram, will show what
needs to be quantified and what is at present already quantified. The next step will
be to find specific indicators to express the dimensions identified. The analysis m a y
exhibit varying degrees of sophistication, but even at its most rudimentary level, it
must draw a clear distinction between the different close-knit subgroups of variables
characteristic of the system, in order to investigate their most important relation-
ships. T h e data selected should be sifted and linked together with the aim of trying
to create a model which will gradually m a k e it possible, as it progresses, to define
the boundaries of the system and set the limits to the study. T h e health system as a
whole m a y then be put back into the overall framework of the social sphere.

Diagrammatic presentation of the health system5

In this brief presentation w e shall confine ourselves to singling out the guiding
principles of the analysis and emphasizing certain results by way of illustration.

The three sub-systems

The 'health service' or 'public health system' is not here taken to m e a n public health
institutions, either as providers of medical care or as responsible for managing
a community scheme for financing expenditure. The focal point of the system is for
us the population's state of health, and it is in relation to this initial point of
departure that the various component parts of the system will be linked together
and co-ordinated.
If w e undertake to list all the factors which contribute to the formation of a
population's state of health, w e soon encounter the large number, diversity and
interdependence of the elements to be taken into account. These include genetic
inheritance, life-style, climatic conditions, cultural level, income level, quality of
medical care, etc. A n element such as the 'quality of medical care' is in turn deter-
mined by a host of other factors such as available resources, the professional ability
of those employed in the public health service, the training system, etc. Each element
can thus be regarded in turn as a new point of departure, and the list of factors
can go on for ever without in any way clarifying the problem. Everything seems to be
connected with everything else is an inextricable w e b of mutual dependence.
Faced with this type of difficulty, one is strongly tempted to yield to an
out-and-out empirical approach and claim that the w e b should untangle itself, if
factors were selected on the basis of a single and purportedly non-equivocal criterion,
 The search for health indicators 443

namely the quantitative effects exercised by one factor on the determination of the
state of health. This myth of a reality which would spontaneously fall into place
through the simple interplay of 'measurements' and observed 'correlations' does not
stand the test of practical experience.
Partial or comprehensive analyses of any kind contribute to the elaboration
of the system, but on this basis there will inevitably arise, at one stage or another
of the study, the need for a logical unity to organize the formless diversity of the
relationships between the elements. F r o m this point of view it must, however, be
recognized that examination of public health processes does not necessarily produce
such a unifying logic. T h e researcher appears to be confronted not with one type of
rationality but several, and there is a great temptation to restrict thefieldof the
analyses to an equivalent number of independent spheres. This would be tantamount
to considering the health system as consisting of various sub-systems, and only
genuinely deserving of being taken as a systemic whole to the extent that, going
beyond this independence, it would be possible to define the ways in which the
various sub-systems depend on each othera form of 'dependence' seen not just
as a contact but as a 'misleading' dependence, 'deviating' from what appears at
first sight to be a specific logic. However, in order to show h o w a specific logic m a y
be 'deflected' by a kind of 'social induction' effect, w e mustfirstof all state the
terms of this autonomy.
T o this end w e have distinguished between three sub-systems (see Figure 2)
whose coexistence within an environment (sets of external factors) sufficiently
indicates the nature of the public health system to allow of embarking on its analysis.

Sub-system Ithe circle of states of health. The first sub-system occupies the central
position which should, as indicated above, be that of the state of health. It describes
the state of health, with the minor difference that it replaces the notion of a state
in the strict sense of the term by that of a developing situation.
Every individual is caught u p in a process leading from one state of health
to another. In particular, he lives through a specific stage which is relatively difficult
to delimit, i.e. his illness. W e speak here of a 'circle' because for each illness the
process takes on a circular form, starting with the appearance of the illness and
ending with its disappearance after passing through specific stages. The idea of this
circular itinerary does not rule out the possibility of indefinite stabilization at one
stage or another of the circle, nor of the decease of the patient.
The w a y in which the itinerary proceeds is determined by a number of
external factors, in particular the impact of the other two sub-systems. W e shall
revert to this aspect of the problem w h e n the other two systems have been described.

Sub-system IIthe health care services. The second sub-system corresponds to the
machinery for the provision of medical goods and services. Like any other pro-
duction system, it is expressed in terms of production factors (facilities, medical
444 Emile Levy

and auxiliary medical personnel, etc.), structures or enterprises, and as such is

governed by technical and economic limitations when, by a combination of these
resources and having regard to technical progress, specific 'products' have to be
procured. These products satisfy in varying measure the public's needs regarding
the improvement of their health, bearing in mind a demand which m a y be explicitly
stated to a greater or lesser extent.

Sub-system IIIthefinancingmachinery. Industrial countries have complex forms

of social organization for spreading thefinancialburden of consumption in the
healthfield.This 'community responsibility' for finance is assumed jointly by
various organizations which form the institutional pattern of Sub-system III.
The internal logical unity of thefirstsub-system consists in the fact that here,
the notion of the individual's state of health is replaced by that of a process which is
ultimately expressed in terms of the behaviour of those concerned. A n analysis of
thisfirstsub-system should m a k e it possible to set opposite Sub-systems II and III
a logic of requirement and demand. T h efirstsub-system is influenced by a host of
factors, such as life-style, cultural level, the impact of Sub-system II, etc. T h e
structure imparted to it should also m a k e possible the satisfactory co-ordination of
the factors which will be taken into account.
The specific logic of Sub-system II is quite different from that of Sub-system I,

External factors

FIG. 2. The three sub-systems.

 The search for health indicators 445

but its 'product' conditions the 'states' in Sub-system I. Here w e are concerned with
the machinery of production.
Sub-system III is afinancingsystem whose language, norms and motivations
are quite independent of those of the other two sub-systems.
Sub-systems II and III are also influenced by factors external to them. T h e
general progress of science in all fields determines developments in the forms
of treatment introduced through Sub-system II, and the very existence of Sub-
system III reflects a whole series of examples of social determination.

Descriptors and indicators

W h e n conducting an analysis of the health system one is confronted with a mass of

quantitative data sometimes referred to as 'descriptors'. In this case, each individual
piece of information is regarded as representative only of itself, bearing in mind the
degree of care with which it has been elaborated. A quantity of diagnoses collected
by the Institut de Documentation et de Recherche Europen sur les Maladies
( I D R E M ) , for example, m a y be taken into consideration for their intrinsic value
alone with n o question of making them into an indicator of a population's health
level.
The transition from the descriptor to the indicator level means that the
quantitative information is required to become 'significant' from a point of view
determined in advance. Let us again consider a series such as the number of all the
diagnoses in clinical medicine, as provided by I D R E M . Trends in this series reveal
trends in recourse to treatment, which are in turn representative not only of a state
of health, of course, but also of a cultural level, a method of providing financial
cover, etc. Thus this number has its o w n inherent complexity and reflects all
together, without any possibility of distinguishing between them, various elements
which are specifically interrelated. If it is not possible to envisage or obtain any
other type of information, w e m a y promote this series to the rank of'indicator' and
consider \\, for example, as significant of the population's level of health. It would
be a poor indicator, though worse have been suggested. W h a t w e have done in this
case is to select, from a m o n g all the descriptors, one series to be taken as an indicator
to 'something' which has been determined in advance, namely the level of health of
the population. W e could have selected several series, keeping them separate or
aggregating them, but the basic point is this: any series derived from a preliminary
observation which adopts as its objective the quantification of the process under
study, is fraught with great complexity even if it is the result of a survey with
specially designated aims. A n especially significant exemple is provided by the
'Soissons' survey, examination of which shows that the number of declared cases
of illness primarily reflects membership of a social group. 6
446 Emile Levy

System indicators and level of health indicators

Bearing in mind the remarks m a d e in the foregoing paragraph, w e consider that part
of the difficulty of working out health indicators stems from the fact that the
researcher is over-ambitious. D o e s defining a health indicator m e a n being
concerned solely with measuring the level of health? A n analysis of the health
system would tend to prove the contrary.
W h e n mention is m a d e of the 'health system' in specialist literature, the
reference in point of fact is frequently to public health institutions, i.e. what w e
earlier called Sub-systems II and III. This habit is not just the reflection of a
vagueness of terminology of little interest. The use of certain expressions is, in fact,
indicative of a general difficulty in the healthfield,which is h o w to establish an
organic link between a 'state' of health on the one hand and health institutions o n
the other. T h e restrictive view of the health system as a group of specialized
institutions ends u p by completely separating the state of health from health
institutions and placing them at two entirely different levels, though this does
notincidentally and paradoxicallyprevent us from considering the former as
basically determined by the latter. With a little over-emphasis on some features, w e
might depict this concept as shown in Figure 3.
This approach to the problem sees the indicator as an index of the 'state of
health' which it measures in degrees, ranging from the best to the worse. In the
absence of such an index, dominated by the dubious assumption that there is a
relationship under which the state of health is unmistakably determined by the
system (institutions), one is forced to promote to the rank of indicator (of the state
of health) some specific index of the equipment or operation of a particular
institution.
The viewpoint to which the analysis of the health system outlined earlier
leads, lies at the opposite extreme from the one described immediately above. It puts

Health system,
i.e.
health institutions

State of health
FIG. 3.
 The search for health indicators 447

Fio. 4.

the state of health at the very heart of the health system, accepts its complexity,
defines a relevant sub-system (Sub-system I), and attempts to demonstrate the
various associations which condition its operation. Examination of the state of
knowledge and the data available incline one, from this point of view, to adopt a
modest standpoint. There is n o single 'association', n o 'element' of the health
system which is not in itself a 'world' of complexity. W e consider that the myth of
the existence of one statistical series, or one index combining various statistics,
capable by itself of revealing health trends in a given country, must be rejected once
and for all.
Thefirstlesson to be learned from the analysis of the health system is that it is
extremely difficult to summarize in a few quantitative data the complexity of
processes of which w e k n o w little. T h e researcher must adopt preliminary objectives
which are less ambitious than the 'measurement' of the level of health itself.
Taking a simplified representation of the health system as the starting point,
and concentrating on Sub-system I and its relations with the other two sub-systems,
w e find thefirststage in the elaboration of health indicators emerging as the
selection and interconnexion of descriptors which are not required to be significant
of the level of health, but to be elements or principal links in the health system. Such
indicators would be called 'system indicators'.
With this in mind four distinct 'centres' have been selected for Figure 4.
448 Emile Levy

W e then propose to define four 'batteries' of indicators:

I Indicators of exposure.
II Indicators of morbidity.
III Indicators of protection.
IV Indicators of result.
In selecting such indicators it would have been possible to adopt m a n y other ways of
arranging the health system and one could devise indicators of the functioning of
Sub-system II, the financing of Sub-system III, etc. The choice m a d e is in line with
the decision to concentrate on knowledge of the state of health.
O n e example will show h o w the project for defining such system indicators
simplifies in part the problem of the transition from descriptor to indicator. A series
such as per capita consumption of alcohol has been put forward as a health system
descriptor. Before making this into an indicator of a population's health level,
it would surely be preferable to require it to be significant of what it indicates m u c h
more directly, i.e. exposure to a risk of ill-health.
Once this initial selection has been m a d e , one can proceed directly to the
problem of the measurement, in the strict sense of the term, of the population's
health level.

In search of a scale of states of health

The justifications for this approach, and its significance

Generally speaking, all studies which raise the problem of health indicators
in terms of health level scales have this in c o m m o n , that they use scales to
aim at expressing the state of health as afinalresult perceived at the level of indi-
viduals or groups. In other words, the reasons for the existence of this type of inves-
tigation are:

A reduction in complexity
Existing data are so numerous and heterogenous that they call for a reduction
in complexity. This complexity in expressing states of health is due to: (a) The
great number of criteria: expressing these states in terms of risk factors, m o r -
bidity, whether as felt by the patient, diagnosed, or objective, ability to carry on
daily activities, suffering, mortality risk, etc., soon leads to a dead end, precisely on
account of the large number of points of view and the impossibility of moving
from one to the other. T h e search for a scale thus reflects an attempt to reduce the
-dimensional phenomenon which the state of health seems to be, to a phenomenon
which can be expressed in one, two or even three dimensions. Fanshel and Bush, 7
like some other writers, thus lay special stress on the ability/disability dimension,
Culyer, Lavers and Williams8 try to combine intensity and duration of the illness
 The search for health indicators 449

with restriction of activity, and C R E D O C associates the morbidity risk (prognosis)

with the degree of disability, (b) The complexity and irreducibility of the types of
language used: the expression of states of health in the language of the health
care machinery, i.e. the diagnosed morbidity, leads to the use of highly complex
nomenclature such as the W H O illness codification. Even w h e n one uses simpli-
fied versions of this nomenclature, the table of states of health in terms of diagnoses
soon becomes unmanageable and, above all, becomes difficult to interpret. T h e
language of symptoms is hardly less complex, and even more difficult to inter-
pret.10 In this respect, the scales proposed have the merit of getting round this
irreducibility and of considerably simplifying the expression of states by using a
finite or small number of degrees.

The orderly grading of states of health

Traditional types of language m a k e little or no allowance for the clear grading of
states of health so as to indicate where 'better' is located and where 'less good' makes
its appearance. Apart from mortality, which indicates one extreme, morbidity
established n o explicit grading between diagnoses. Furthermore, the notions of
cure, stabilization, etc., do not lend themselves to measurement, as everyone knows.
The classification of diagnoses in terms of the suffering, mortality risk, or disability
which characterize them is thus one w a y of establishing a grading and of dis-
tinguishing better states from worse ones. A n y social indicator must be capable
of expressing the improvement or worsening of a situation. Thus the logical and
obvious solution to this problem is to look for a scale with several degrees.

Co-ordinating the resources to be used with observed

or envisaged levels (states) of health
If public health planning is to be consistent, the programming of the resources to be
used must be co-ordinated with ultimate aims and needs.
This is the working standpoint of J. Lave, L . Lave and S. Leinhardt11 w h o
consider that in order to avoid programming from day to day, public authorities
should adopt consistent health objectives. They distinguish between four possible
approaches:
Thefirstwould be to provide each individual with the best quality medical care, but
the physical and financial bottlenecks encountered, both short- and long-term,
are such that this is an impracticable objective.
The second would be to give all members of the community equal access to
treatment, but a reduction in the cost of access for the least privileged
categories is likely to create a considerable increase in the d e m a n d for
treatment which, given only a slight increase in the supply, can only result
in raising the cost for all.
The third would be to provide treatment for all those w h o would thereby be enabled
to return to work, provided that the cost of treatment is less than that of
450 Emile Levy

welfare assistance; but this is a meagre objective (in strictly economic terms)
and one which is morally objectionable.
The fourth, the only reasonable one, would be to provide a sufficient quantity of
medical treatment to maintain a level of health adopted as an objective for the
population as a whole. For this, one must be able to express the level by
means of a scale with several degrees (see below).
W h a t is thus basically revealed by all these tentative approaches is that medical
services are only one of the inputs into the health status, side by side with m a n y
others such as nutrition, housing, hygiene, working conditions, etc. It is even
generally acknowledged that the other inputs are still m o r e decisive than medical
care, and that it m a y well be possible to improve the health situation by acting on
them rather than on the health service. The development of the health service must
nevertheless be organized by adapting it to the recognized ultimate aim, which
is to improve the state of health and to alleviate suffering. O n e must therefore be
able to express its results accordingly, and to relate the means used to these ends.

How to constitute the 'scale'

Using a descriptor of the health system as an indicator of the health level

T o develop a 'scale' of a population's state of health, w e can look for a statistical
series which would, for reasons which should be analysed, 'spontaneously' produce
a synthesis of the countless elements of which a population's state of health is
composed.
It is noticeable that authors w h o use such indices usually look in the direction
of'mortality', which seems less ambiguous. The series most often used are probably
life expectancy, the general standard mortality rate and infant mortality.
Generally speaking, it must be acknowledged that from certain points of
view these series do provide a composite evaluation of the state of health of a
population, its exposure to illness, its actual illnesses and the protection afforded
toit.
T o test their validity, one would have to assume that the problem was already
solved, and be in possession of a genuine index of the level of health with which these
series might be compared. Researcheis have soon felt the need to go beyond such
partial representations and if the synthesis 'spontaneously' yielded by the series has
turned out to be inadequate, have attempted to m a k e good the shortcomings by
'combinations' of separate series.

Constituting a scale by combining descriptors

The most revealing example which can be quoted in this connection is that of the
United States indicator used in the Olson report:12 'life expectancy excluding
confinement to bed', which 'corrects' life expectancy prolonged through confine-
ment to bed by introducing the simple idea that it is not sufficient for the population
 The search for health indicators 451

to survive to be able to consider that it is in better health. In this case confinement to

bed is held to be as m u c h a burden as all the 'unpleasantnesses' for which a
deterioration in health m a y be held responsible. A n example of a more subtle
analysis, incidentally oriented towards very different aims, is given by the C R E D O C
indicator which integrates mortality into the expression of mortality risk, and
restriction of activity into the expression of 'disability'. It should, however, be
noted that the criteria for such combinations always remain very arbitrary: only
where experts tend to 'concur' would it be possible to reach a decision. If the
overriding aim is to achieve this type of 'weighting' of states, this w a y of
elaborating an indicator of the level of health seems one of the few feasible
ones.
W e have already mentioned the studies by Fanshel and Bush and the proposals
m a d e by Culyer, Lavers and Williams, and the list of experimental investi-
gations being carried out on the basis of a scale of states of health is growing longer
every day.
For example, in the United K i n g d o m , R . Rosser and V . Watts 13 have tried to
measure the 'health output' of a hospital by classifying admissions to and discharges
from St Olave's Hospital o n two scales combining the degrees of disability and the
degrees of suffering and/or mental disequilibrium. With 8 degrees for the former
(ranging from 1 : no disability to 7: confinement to bed, and 8: loss of consciousness)
and 4 degrees for the latter, depending o n whether suffering is slight, moderate,
severe or nil, they arrived at thirty-two possible ways of classifying patients, which
forty-eight doctors were asked to use. T h e effectiveness of the treatment provided
was measured by the difference between the matrix of admissions and the matrix of
discharges.
Similarly, the L o n d o n Institute for Operational Research, on behalf of the
Ministry of Health, prepared a classification of the elderly with a view to deciding
what resources should be used to satisfy their needs. The classification comprised
five scales:14
O n e scale for the ability to be active in the house and look after oneself, or a scale
of autonomy (4 degrees).
O n e 3-degree scale of mobility or physical ability.
O n e 3-degree scale of mental equilibrium.
O n e 3-degree scale indicating isolation or nearness of relations.
O n e 2-degree scale for the physical environment or h o m e comforts.
The institute also divided patients in a hospital department into four categories
comprising the critically, the seriously, the moderately and the slightly ill, so as to
define, for each category, the precise type of care to be given by the nurses, and to
plan their work. 1 5
In the United States, Judith and Lester Lave and S. Leinhardt18 have devised
a simulation model for the distribution of medical care, based on a 5-degree scale
of states of health, depending on the gravity of the symptoms: (a) no symptoms: good
452 Emile Levy

health; (b) slight disorders; (c) acutely ill patient; (d) critical condition; (e) death.
These are, however, subjective criteria, related to the level of morbidity experienced,
and were to be used as a possible basis for calculating the likelihood of recourse to
treatment. This list of examples does not have to be extended for it to be apparent
that there is a clear trend towards depicting a population's health status on the basis
of one or m o r e scales, and even ultimately of a single index with aggregates the
results recorded by these scales.

Promoting a system indicator to the rank of health-status indicator:

the example of indicators of exposure
A s w e have seen, the circle of states of health has a certain inherent degree of
complexity, even if described in a fairly s u m m a r y way. In the absence of any
consistent data illustrating each state and the transition from one to the other, there
is a very natural tendency to lay emphasis on one state, and to give a m u c h wider
significance to thefiguresrelating to it. For a very long time n o w , for instance, death
has been considered an outstandingly important statistic (on account of its
objective character), and mortality data are used as significant of the population's
overall health status.
Faced with the shortcomings of mortality indicators, epidemiologists have
been obliged to consider whether, to express the health level, such indicators should
not be replaced by indicators of exposure, i.e. data on the risk of illness run by the
population."
Basil S. Hetzel comments as follows on the inadequacy of traditional mortality
indicators (infant mortality rate, crude mortality rate, expectation of life).18
Thefirstdrawback he sees is that the levels attained by these indicators can
only be accounted for by reference to data on the environment. This is true of the
Australian aborigines, for w h o m the very unfavourable level shown by these
indicators can only be explainedbearing in mind that medical facilities are m o r e
than adequateby poor conditions of hygiene, nutrition and housing and b y
beliefs which are inimical to improvement under such conditions. It is also true of
developing countries where the recent downward trend in the mortality rate reflects
action on the causes of mortality such as malaria and dysentery or is related,
generally speaking, to an improvement in the physical environment, whereas
progress is most limited in relation to illnesses where high-quality medical services
are necessary. It has been true,finally,of developed countries in the last hundred
years. In the United K i n g d o m between 1850 and 1900, a substantial fall was recorded
in deaths from tuberculosis (50 per cent), as well as from typhus, typhoid and
cholera (23 per cent), and these trends can be attributed to diet and a properly
organized water supply. Similarly, the sharp fall in the infant mortality rate from 150
in 1910 to 30, is an improvement due to the educational influence of pediatric and
maternity services for mothers.
The second drawback is that indicators related to mortality m a y no longer
 The search for health indicators 453

m e a n anything because they display n o significant trends, a phenomenon which can

itself be accounted for by a worsening in environmental conditions. It is c o m m o n
knowledge that life expectancy at the age of 40 or 65 has increased very little since
the beginning of the century and has been stationary since the 1950s. This is because
the main causes of death in the Western world are lung cancer and chronic
bronchitis due to smoking, and accidents, half of which are road accidents caused
in 50 per cent of all cases by excessive consumption of alcohol.
In other words, the morbidity and mortality which are characteristic of the
so-called developed countries are linked to features of the urban way of life so that
the only indicators capable of accounting for this situation are precisely those which
express the risks run by town-dwelling populations. Data descriptive of housing
conditions, diet, education and the quality of family, working and social life are thus
probably the data which express the health level, or at least explain the health status,
most effectively.
W e thus come to the apparent paradox, that in order to express health levels
w e should refer to data taken not from the medical sectorin the strict sense of the
termbut from the social and economic environment. This amply demonstrates
that a set of social indicators is always 'open-ended', even if, in order to facilitate
the analysis, social life is divided into 'problems' or 'sectors'. In one case the
'health' indicatorsfinallyelaborated m a y also be data about housing or education;
elsewhere, indicators of success at school or work m a y be sought in health
conditions, etc.

The difficulties and disadvantages of these solutions

O n e cannot fail to be struck by two aspects of the studies being conducted in

connection with the notion of a scale of health levels.
T h efirstis the extreme simplicity of the idea underlying this investigation.
W h a t can be more natural than to seek to break these states d o w n into degrees, and
to translate into quantitative and general terms evaluations which are implicit, and
even explicit, in the everyday behaviour of individuals?
The second is the danger of believing that there exists a 'gimmick' which will
solve the problem, as pointed out in thefirstpart of this study. This is a belief to
which it appears all authors fall victim. W h a t , indeed, can be more attractive than
the idea of a simple instrument for measuring the state of health, like a system of
weights and measures to work out the weight and height of an individual? With a
scalar like this, w e would surely be in a position not only to k n o w about a health
situation, but also to assess the effects of the medical system or of specific pro-
grammes for community action.
The following objections should be m a d e to such tempting arguments:
1. T h e reduction in complexity is arguable: when a criterion (that of individual
ability/disability) occupies a preponderant place in the scale, it cannot be claimed
454 Emile Levy

that the other dimensions have been included (suffering, duration, nature of the
illness, mortality risk). This is an option or an aspect which it has been decided
to emphasize, and this choice m a y always be questioned.
2. In cases where there are a number of criteria, they will be combined on an
empirical and ad hoc basis, i.e. in relation to an age group or type of illness. For
instance w h e n considering the elderly, aspects such as physical autonomy or
mental equilibrium, and even the degree of loneliness, will very naturally be
taken into account, whereas scales constructed for children or adults will
emphasize other aspects of their state of health. Elaboration of a scale valid for
all groups thus seems to be impossible since the specific aspects of the states of
health to be taken into consideration vary from one group to another.
3. W h e r e several components of a state of health define one and the same level,
'equivalences' should be established.
By w h o m ? H o w ? T h e opinions of experts (doctors) which the French,
British or American studies m a k e use of are an unconvincing solution when it
comes to graduating levels of suffering or establishing equivalences between
illnesses differing considerably from the point of view of mortality risk and
disability.
A s for the 'indifference curves' suggested by Williams for graduating
numerous combinations of suffering and restricted activity, these are a somewhat
'forced' borrowing from the language of micro-economics, and it is doubtful
whether they can be measured in a reliable way. 1 9
Moreover, every author proposing a scale will define its relevant
categories (the different degrees) as being either 'objective' (expert opinions, for
instance) or subjective (cf. the study by Lave and Leinhardt quoted above, in
which each individual classifies himself at the particular level of morbidity he
experiences). A fortiori the problems of the weighting and equivalence of states
according to the population groups concerned, seem difficult to solve. Is a
'one-point' improvement in the state of health of young people equivalent to the
same improvement for adults or elderly people? Does the same hold good for
agricultural labourers and executives, etc.?
4. Defined as reducing complexity, the health indicator, based on a scale of several
levels at which it is claimed individual cases can be situated, also reduces the
level of information. The expression by one vector or by a single figure of a
situation which contains such a wealth of information m a y have certain
advantages, but has the drawback of entailing a substantial loss of data,
including precisely those data which would be the most useful to the planner.
The major areas of present-day pathology and the main categories of k n o w n risk
factors, which cease to be shown as such in this system of indicators, surely have a
function as pointers to the activities which need to be put in hand.
It is major disadvantages like these that have led us to seek in other directions
for a quantitative approach to the level of health.
 The search for health indicators 455

Building up a picture of health status

If w e set aside the notion of a scale of health states, and try to get away from reducing
health status to one or other of its component parts, where can w e situate the
problem of evaluating the population's health level? W e have defined what w e have
called 'system indicators' which provide a battery of indicators for each of the
basic links in the health system. T h e last hypothesis examined regarding the
evaluation of health levels, took one of these batteries of system indicators as
indicators of the health level. Indicators of exposure were, for example, considered
as representative, in themselves, of the population's level of health. This directly
suggests an interesting line of research.

Building up a picture of health status using the battery ofsystem indicators

T o evaluate a population's health level, it is not enough to ask to what extent the
population is 'exposed'. The vital, associated question must also be asked: is the
population satisfactorily protected? O n e then naturally goes on to inquire whether it
is affected by illness, whether it is keenly aware of it, etc. In the last analysis, a basis
for a general evaluation of the health level of the population in question will be
provided by an examination of the overall table of system indicators. F r o m the
general table of system indicators: exposureprevalence of illnessprotection-
effectivenessresult, there emerges what can be called, not a direct measurement,
but a complex picture of quantitative data about the health level. Taken in isolation,
the system indicator reflects only the specific link in the health system which it has
been constituted to express. However, the general table of these partial indicators
completely transforms the significance of each series, which tell us far m o r e when
they are compared with the other parts of the table.
Confining ourselves to essentials, and bearing in mind what will have to be
abandoned because of the inadequacy of the information available, w e have
attempted to draw u p Table 1 for the population of France.
In each case reference can be m a d e to the analysis of the health system in
which a greater number of descriptors m a y be introduced.
This table directly reflects the categories selected for the analysis of the
health system, and is organized having regard to the four types of system indicator
adopted. It will be noted that the basic links in the table correspond explicitly to the
'itineraries' shown diagrammatically in Sub-system 1.
In considering the various proposed headings, one should bear in mind that
the series worked out should be regarded as representative of the entire range of
data reproduced, and that there cannot be any 'interpretation' of an isolated piece
of information. Table 1 is not the one and only table or indicators, and does not
yield, intrinsically, any image of the health status of the French population. It is
nevertheless true that a regular yearly follow-up to such series, or an international
456 Emile Levy
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458 Emile Levy

comparison, or any differential study such as will be proposed below, should allow
salient developments or the specific nature of the parameters which describe the
health status of certain populations, to be highlighted. T o deduce an improvement
or decline in the population's health status from the observation of trends in the
component elements of exposure, protection, prevalence of illness, and the final
outcome of the processes of morbidity, raises considerable problems to which w e
shall briefly refer.
W e feel that two main types of objection can be m a d e to this form of
presentation: H o w should one interpret the results obtained? W o u l d the represen-
tation established be independent of the objectives sought? W e discuss these two
problems below.

Difficulties of interpretationevaluation of the health level

H o w could the table of system indicators be used to evaluate a level of health?

Chronological trends, a comparison of social groups or a comparison of notions,
do not lend themselves to any immediate interpretation. Each type of indicator
reveals differing situations, and a comparison can only be m a d e element by element.
O n e group will be more exposed than another from a particular point of view and the
peculiarities of these different kinds of exposure are to be found at the level of both
the prevalence of disease and the results. T h e ways in which protection is afforded
differ, and it is not possible to arrive at genuine equivalences. Analysis of health
levels, or in other words, interpretation of the series suggested, presupposes the
genuine establishment of models for the processes involved.
Interpreting the sets of series adopted seems a paiticularly delicate operation,
in that none of the descriptors selected in preparing the system indicators can ever in
any circumstances be considered as independent.
The fact is that both in order to understand and to take action, one must be
able to demonstrate the m a n y associations existing between the descriptors adopted
and ultimately to specify those which appear to be the most important, w h e n the
field for analysis is confined to one specific objective. If one is chiefly concerned with
the problem of health status and its determinants, one ends up with a certain
representation of the basic interactions in relation to the three concepts of objective
morbidity, morbidity as felt by the patient and diagnosed morbidityas shown
in Figure 5.
For instance there exist different descriptors related to the concept of
objective morbidity which, depending on the point of view adopted, will fall into
the category of indicators 'of prevalence of disease' or 'of result' (depending on
whether one is, or is not, concerned with a state of health subsequent to specific
treatment from the health system).
This objective morbidity itself will at the same time, also be determined by a
whole group of other elements related to exposure torisk,morbidity as experienced
 The search for health indicators 459

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FIG. 5.
460 Emile Levy
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 The search for health indicators 461

by the patient, etc. If these things are to be taken into account, it will be necessary
to select, in a more accurate way, a unit of time over which to study the phenomena
involved, and to indicate the geographical level or social group to which the analysis
refers. Briefly, this approach leads to the construction of a model which is, to a
great extent, determined by the information available and the end sought. However,
the model is herefilteredthrough the overall system analysis which logically
preceded it, and whose main concept it uses, subject as necessary to admitting the
impossibility of representing certain aspects in a quantitative way.
The wrong way of approaching the modelling problem is to assume that it
has already been solved, and to claim that the variables can be tested by reference
to a series which is representative of the health level. The fact is that the attempt to
construct a model can never be based o n the end sought, namely the evaluation
of the population's health status. It can only be successful if it is thought of as a
synthesis of the findings of the most varied studies, with borrowings from psy-
chology, sociology, epidemiology, specifically medical knowledge, etc. The analysis
of the health system that w e have attempted does not lead to a model, since a model
seems totally inconceivable in the present state of knowledge and information. A t
this stage in our discussion, this analysis takes o n a new significance. W e see that
the primary aim has been to try to state the basic concepts and demonstrate and
quantify as far as possible the basic links in order to provide the reader with guide-
lines for a possible, and necessarily complex, interpretation of the components of
the general table w e have worked out.

A d hoc presentation for each problem

Table 1 corresponded to the very general objective of evaluating a population's

health status. It is easy to see that the choices m a d e and the level of breakdown
adopted should reflect a more accurately definedfinalaim. There does not exist
any single battery of indicators which would be appropriate for all the objectives,
and it is in the light of the study in hand that choices should be m a d e . T o illustrate this
'relativity' of choice w e give the example of inequality.
Inequality will be examined from two main viewpoints, namely, inequality
linked to membership of a socio-professional category, and inequality as observed in
the different regions of France.20 In both cases w e have attempted a breakdown of
the data presented in thefirstparagraph. The breakdown was possible for only
some of the series adopted. W e were thus obliged quite simply to abandon certain
figures, or replace them by other series which were in some cases less significant
(see Table 2).

Socio-professional categories
While it is not possible, on the basis of such restricted quantitative information, to
interrelate the components (exposure, prevalence of illness, etc.) so as to bring out
462 Emile Levy

this 'picture' of the health status of socio-professional categories, it is our view that
the following inference can be m a d e . Membership of a socio-professional category
with a low income level and low level of culture, has its corollary in a poorer level
of health, and vice versa. T h e following points can be noted:
Exposure is increased (e.g. alcohol consumption).
Studies by C R E D O C show that people in these categories have recourse to the
health service less than others.
Declared cases of illness followed by serious ill-effects are more numerous in these
categories. The total number of cases of declared illness reveals both the
difference in objective morbidity and the difference in each individual's
capacity to perceive and express the morbidity felt. M e m b e r s of the working
class report an average number of cases of illness, but their illnesses lead to
major disorders and entail long periods of hospitalization. Conversely,
higher management personnel fall sick relatively rarely, and very rarely
suffer from major disorders (the short duration of hospitalization also
reflects the use of other types of treatment).
Lastly, note should be taken of the importance of accidents and suicide as a cause
of mortality in the working class and a m o n g agricultural workers.

The regions
The breakdown by regions highlights regional disparities which are already k n o w n ,
such as the over-provision of facilities in the Paris region, in terms of both personnel
and hospital beds, in comparison with the under-provision noted in the north of
France. This seems to entail important differences as regards the number of days of
hospitalization reimbursed by the national health service per inhabitant, which is
twice as great for the Paris region as for the north, and also as regards the l de facte?
infant mortality rate, which is one-and-a-half times greater in the north than in
the Paris region. This rate is moreover very m u c h lower then the average for
France. O n the other hand, only very slight variations are observed in the
average age of death, the south-west being the region where people apparently
live the longest.
These two tables thus show us that in France, important differences exist,
both at regional level and at the level of socio-professional categories, in the figures
which are supposed to represent, or at least give some indication of their health
status. A reduction in these inequalities could be associated with a relative
homogenization of these data.
[Translated from French]
 The search for health indicators
Notes
1
R . E . Bickner, Measurements and Indices of Health
in Methodology of Identifying, Measuring and
Evaluating Outcomes of Health Service Pro- 10
grammes, Systems and Subsystems, Confer-
ence Series, 1967, Health, Education and
11
Welfare Department, Public Health Series,
Health Services and Mental Health A d -
ministration, Washington, D . C .
2
Towards a Social Report, United States Depart-
ment of Health, Education and Welfare,
Washington, D . C , 1969.
3
cf. a m e m o r a n d u m by the French Commissariat
12
Gnral du Plan dated 27 July 1969 which
13
defines a number of criteria such as the sen-
sitivity, accuracy, univocal significance and
composite character of social indicators.
4
J. Hamburger, La Puissance et la Fragilit, Paris,
14
Pln, 1972.
5
For a study in greater detail see: . Levy et al.,
conomie du Systme de Sant, Paris, Dunod,
1975.
6 15
Survey carried out by the French Institut National
de la Sant et de la Recherche Mdicale
16
( I N S E R M ) on the health needs of the popu-
17
lation of the town of Soissons, between
November 1966 and November 1967.
' S. Fanshel and J. W . Bush, ' A Health-Status
Index and its Application to Health Services
Outcomes', Operations Research, Vol. 18, 18
N o . 9, November-December 1970.
8
A . J. Culyer, R . S . Lavers and A . Williams,
'Health Social Trends', Social Indicators, 2, 19
20
1971.
9
A . Mizrahi and A . Mizrahi, ' U n Modle des D -
penses Mdicales Appliqu aux Donnes
463
d'une Enqute', Consommation, Annales du
CREDOC, 1, 1964.
B . C . Morrei, ' S y m p t o m Interpretation in General
Practice', Journal of the Royal College of
General Practitioners, 22, 1972, p. 297.
J. Lave, L . Lave and S. Leinhardt, 'Modelling the
Delivery of Medical Services', report sub-
mitted to the A I S E Symposium on l'conomie
de la Sant et des Services Mdicaux, Tokyo,
2-7 April 1973, and reproduced in M . Perlman
(ed.), Economies of Health and Medical Care,
London, Macmillan, 1974.
Towards a Social Report.
R . Rosser and V . Watts, 'The Measurement of Hos-
pital Output', an address to the Operational
Research Society Conference, Lancaster,
United Kingdom, September 1971. (Roneoed.)
M . Luck and Colin Wiseman, 'Classification of
the Elderly, Social Independence States',
Institutefor Operational Research, July 1972.
(Roneoed.)
Institute for Operational Research, working
documents, 1972-1973. (Roneoed.)
ibid.
This means promoting one of the 'batteries' of
system indicators described in the preceding
section to the rank of'indicator' of the popu-
lation's health level.
B . S . Hetzel, ' T h e Implications of Health Indica-
tors. A C o m m e n t ' , International Journal of
Epidemiology, Vol. 1, N o . 4 , 1972.
Culyer, Lavers and Williams, op. cit.
The socio-professional categories and the eight
regions used correspond to the I N S E E defi-
nitions.
 A n ecological analysis
of national health in Japan

Mikio Yamamoto with Chikio Hayashi

Hiroaki Terao, Kazue Yamada

Introduction

In order to maintain the health of a population it is essential to have an under-

standing of h u m a n life.1 T o this end the author chose an ecological approach to his
study since he sees it as both compatible with his Buddhist beliefs and useful when
applied to health planning. H u m a n ecology presupposes a clarification of the
structure and functions of life and the author, as an ecologist, sees life as
a pattern of environmental relationships which is an expression of dynamic
equilibrium.2
Although this ecological approach to health planning is not yet fully
developed, the progress of computer sciences in Japan has m a d e a relatively
comprehensive approach possible. Health planning attempts a rational promotion
of the health of a population and in order to achieve this, a stable health model
mustfirstbe established.3 Although small-scale community health surveys were
carried out by Y a m a m o t o 4 and Miyasaka 5 in 1956, and by others,' serious attempts
to set up a health model in Japan are scarce. This study's original aim was thus
to create such a model on both a national and prefectural level.
The author and his colleagues began by listing the influence of living con-
ditions on health. After three years of comparative study in 1960, 1965 and 1970
severalfindingsemerged. The health model, however, is still being developed.
W e hope that this study will serve as a comprehensive approach to the life
of the Japanese people.

Mikio Yamamoto is Professor and Head of the Department of Public Health, Teikyo University
School of Medicine, 11-1 Jaga 2 chme, Itabashi-Ku, Tokyo 173 (Japan). He is a member of a
large number of associations and societies and founded the General Japanese Society of Compre-
hensive Health Care in 1966 and his career includes periods as a naval surgeon, a labour standard
inspector and delegate to different international conferences. He is regional editor of Social
Science and Medicine, an international journal.

Int. Soc. Sei. J., Vol. X X I X , N o . 3, 1977

An ecological analysis of national health in Japan 465

Previous studies

A series of papers whichfirstappeared in 1965 entitled 'Ecological Studies on the

Health of the Japanese People' by M . Y a m a m o t o and D r E . S. Rogers et al. of the
School of Public Health, University of California, compared the influence of
various environmental factors on the health of the people of Japan and the United
States.7 Following this comparative study, Mikio Y a m a m o t o began a similar
interdisciplinary observation in Japan in 1966, using multivariate analysis (corre-
lation, multiple regression and principal component analyses in addition to
Hayashi's Theory of Quantification IV) 8 with the collaboration of economists,
sociologists, statisticians and public health researchers (fifteen people in all) and
using Japanese-compiled data.
The results obtained from analysing 362 indices on the prefectural level were
referred to on such occasions as at the meetings of the Japanese Society of Public
Health;9 Japanese Society of Hygiene; 10 Japanese Society of Race Hygiene; 11
Population Association of Japan; 12 the First International Conference o n Social
Science and Medicine (Aberdeen, 1970) and the Fourth International Conference on
Social Science and Medicine (Elsinore, 1974) and others.13 A n d several other
reference materials were published.14

Materials and methods used

Thirty-one health andfifteenenvironmental indices were compiled in 1960, 1965

and 1970. The health indices included life expectancy at birth; height and weight
of children and standardized mortality rates. (The latter were seen as an important
indication of the overall death structure.) Thefifteenenvironmental indices selected
were judged to be the most significant variables related to health. W e tried to reduce
the number of correlated indices (see Table 1).
Animal protein and the total a m o u n t of calories in food purchases were
evaluated by the authors using three different sources15 and these nutritional values
were used along with other data in all the analyses.
Before beginning correlation analysis, twelve environmental indices (ex-
cepting 203, 204 and 215) were modified using the Hayashi modification formula
to reduce the influence of urbanization which, in past studies, had been seen as
strongly affecting the population's health.
466 Mikio Yamamolo with Chikio Hayashi
Hiroaki Terao, Kazue Yantada

T A B L E 1. List of indices

Health Environment

101-102 Male and female life expectancy at 201 Animal protein purchased
birth 202 Total calories purchased
103-104 Male and female standardized death 203 Average rainfall
rate ( S D R ) 204 Average temperature
105-106 Male and female S D R due to 205 General clinics per person
cerebrovascular disease 206 Medical workers per person
107-108 Male and female S D R due to heart 207 Hospitals per 100,000 persons
disease 208 Average family size
109-110 Male and female S D R due to 209 Married people per person over 14 years
malignant neoplasms 210 College enrolments per high-school
111-112 Male and female S D R due to graduate
pulmonary and bronchial cancer 211 College graduates per person over
113-114 Male and female S D R due to 14 years
stomach cancer 212 Car owners per 1,000 persons
115 Female S D R due to uterine cancer 213 Primary industry workers per employed
116-117 Male and female S D R due to liver person over 14 years
cirrhosis 214 Prefectural distribution of incomes per
118-119 Male and female S D R due to capita
tuberculosis 215 Ratio of population in densely inhabited
120-121 Male and female S D R due to areas
pneumonia and bronchitis
122 Death rate due to other causes
(involuntary)
123 Standardized suicide rate
124-125 Average male and female height at
6 years
126-127 Average male and female weight at
6 years
128-129 Average male and female height at
14 years
130-131 Average male and female weight at
14 years

The Hayashi formula

Y 8X=Z
XV

Y = original value of normalized index to be modified;

X = value of normalized index through which modification is carried out;
Z = modified value of Y (Z means the residual from the regression line to Y
by*);
8 = correlation coefficient between Y and X.
An ecological analysis of national health in Japan 467

T o reduce the influence of urbanization, the proportion of the population in

densely inhabited areas was used as the value of X.
In the case of animal protein purchase, it was modified in a similar w a y
by total calories of food purchased and then was modified again by densely
inhabited areas.

Methods of analysis and the results

Although m a n y multivariate analytic methods were employed, this report is mainly

concerned with the use of correlation analysis on health and environmental indices.
The results obtained from both simple and multiple correlation analyses are shown
in Table 2.
In the case of health indices (with the exception of male and female standard
death rates (SDR)due to heart disease: 107 and 108) a significant multiple
correlation was observed with the environmental variables. The latter were found
to have a particularly strong influence on life expectancy (101 and 102); the S D R
for all causes of death (103 and 104) and the child growth rate (124-131).
Variables concerning urbanization (215) and higher income (214) were found
to have a favourable influence on such comprehensive indices as life expectancy,
the S D R and the child growth rate; whereas living in rural areas was seen to have
an unfavourable influence on health. Animal protein purchases were particularly
favourable in the case of the child growth rate and somewhat less in that of the
general life expectancy. Car ownership (212) had a favourable influence on the
population in general and a w a r m average temperature (204) as well as fewer family
members (208), on the health of the female population.
The numbers of medical workers and college graduates per person did not
significantly influence such comprehensive indices as life expectancy at birth;
the S D R and the child growth rate.
A highly unfavourable influence by the following environmental variables was
observed in the case of the S D R due to cerebrovascular disease (105 and 106)the
main cause of death in Japan: higher calorie purchases (202); cold average tem-
perature; agriculture and larger famines. The greater the per-person rates of general
clinics (205); hospitals (207) and car owners, the more favourable the influence on
this type of death rate.
Significant influences on the death rate due to heart disease by the fifteen
environmental variables were not observed, except to a small extent in the case of a
w a r m average temperature (for the male population). This suggests that no
significant effect on this death rate would be obtained through an improvement of
the environmental variables.
The same applies to the death rate due to malignant neoplasms, although
a reduced calorie intake and smaller families were found to have somewhat
 468 Mikio Yamamoto with Chikio Hayashi
Hiroaki Terao, Kazue Yantada
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An ecological analysis of national health in Japan 469

favourable effects o n the death rate due to stomach cancer (113 and 114).
A high calorie intake was found to have a significant favourable effect o n
death due to uterine cancer (115). A w a r m average temperature and a high rate of
hospitals also had favourable effects.
Although a recent decrease in the Japanese death rate due to uterine cancer has
been attributed to the increasing number of regular uterine examinations, an
improvement in the above-mentioned environmental conditions is seen as c o m -
prising and effective counter-measure.
The influence of these conditions also applies to liver cirrhosis (116 and 117)
tuberculosis (118 and 119). A n especially significant and favourable correlation was
determined between death caused by tuberculosis and a high calorie intake. Indeed,
high-calorie food is often administered to tuberculosis patients as part of their
treatment.
Death due to pneumonia and bronchitis (120 and 121) was found to be
favourably effected to a significant extent by a higher level of animal protein;
low-calorie food, smaller families and industry as opposed to agriculture. The same
tendency was observed in the case of a w a r m average temperature and, to a lesser
extent, the rate of clinics per person.
The high death rate due to pulmonary cancer in urban areas appeared to be
caused by pollution of the atmosphere, a result of Japan's rapid industrialization.
This observation has drawn attention to the necessity of combating air pollution
through industrial controls.
In conclusion, the varying influences of environmental factors on the Japanese
death rate should be seriously taken into consideration in the establishment of a
model for health planning. This applies especially to those factors found to have a
stable or highly significant influence during the three years of study.

Observations

W e are continuing our data analyses and will soon be working on the 1975 census
which is to be published shortly. Since some unstable relationships were observed in
correlating health and environmental variables over the three years chosen, w e
are also analysing data from 1959, 1961, 1964, 1966, 1969 and 1971. This means
that w e will be working with three sets of data in groups of three consecutive years
allowing a stabilization of data values.
The low value of multiple correlation coefficients and the wide differences in
relationship observed over the initial three years studied showed that the environ-
mental variables chosen were not sufficiently comprehensive. Thus, for example,
in the case of specific standard mortality rates, w e have added other variables in
order to have a wider understanding of the influence of environmental factors.
W e are n o w using simulation analysis to evaluate our health model. Since
 470 Mikio Yamamoto with Chikio Hayas/ti
Hiroaki Terao, Kazue Yantada

our analyses were restricted to the prefectural level, w e are examining the K a n a g a w a
Prefecture's m a n y types of municipality (industry, tourism, trade, agriculture,
fishing, etc.). O u r aim is to study the possibilities of health planning on the
municipal level. Following several years of macroscopic research, w e are n o w
carrying out microscopic surveys in two neighbouring municipalities of the
K a n a g a w a Prefecture. Although the two municipalities are industrially similar,
their health statuses are very different. Through this project w e also hope to
contribute to the development of health planning at the municipal level.

Summary and conclusion

A s afirststep towards the development of a health model, relationships between

thirty-one health andfifteenenvironmental indices were observed in 1960, 1965
and 1970. (These years were marked by rapid industrialization in Japan.) Through
comparative methods the authors noted m a n y factors which significantly influenced
(either favourably or unfavourably) both comprehensive indices such as life
expectancy; and specific indices, for example, death due to cerebrovascular disease.

Acknowledgements

Haruo N a g a o established the Regional Information Study Group (Chiikijoho

Shori Kenkyukai) in 1968 to sponsor our study. The association continues to give
financial support to our projects.
W e have also received assistance from other organizations such as the
Ministry of Health and Welfare (in 1970); the Kanagawa Prefectural Government
(1975-76); the Shizuoka Broadcasting C o m p a n y (1962-70) and the Shizuoka
Health Care Center (from 1971).
The President of the Century Research Center, M r Tsukamoto, allowed us
to use the centre's computer services.
I would like to express our sincere gratitude to all w h o have m a d e this
research project possible.

Notes

1
Mikio Yamamoto et al., 'The Development of
the Social and Health Sciences in Japan',
Social Science and Medicine, Vol. 3, 1970,
p. 639-52.
a
Mikio Yamamoto, 'Ecology and Prospect of
Health and Medical Care in JapanEcology
of Health', Juntendo Med. Journal, Vol. 17,
1971, p. 17-23; Edward S. Rogers and
Harley B . Messinger, ' H u m a n Ecology:
Toward a Holistic Method', Milbank Mem-
orial Fund Quarterly, Vol. X I V , N o . 1, 1967,
p. 25-42.
An ecological analysis of national health in Japan
Notes (continued)
3 7
Mikio Yamamoto et al., A Draft of Community
Diagnosis. Ikuseikyo Report, 1960; Mikio
Yamamoto, 'Chikushindan no Katsuyo [Util-
ization of Community Diagnosis]', J.P.H.
Practice, Vol. 30, 1966, p. 700-5; Mikio
Yamamoto, ' H o w to meet the Health
Needs of the Community?', Seikatsu Kyoiku
[Life Education Series], Vol. 12, 1969,
p. 41-65; Mikio Yamamoto, 'Health Plan-
ning', in Dr Royama (ed.), Shutoken no
Miraizo [The Future Pattern of Metropolitan
Area], 1969, p. 253-301; Mikio Yamamoto,
'Health Planning (Review)', Igaku no Ayumi
[Trend in M e d . ] , Vol. 70, 1969, p. 178-82;
Mikio Yamamoto, 'Kagaku Ippan Ron to
Hokenkagaku no Tachiba kara Mitta Kodo-
keiryo-Gaku no Kadai [Subjects of Behav-
iormetrics from the View Point of Science
in General and Science of Health]', The
Japanese Journal of Behaviormetrics, Vol. 1,
1974, p. 30-8.
4
Mikio Yamamoto (ed.), A Case Report on the Joint
Research of Model Village, p . 366, Tokyo,
Juntendo University, Department of Public
Health, 1957.
6
Tadao Miyasaka, ' A n Evaluation of a Ten Years
Demonstration Project in Community Health
in a Rural Area in JapanChiyoda Mura
Health Project', Social Science & Medicine,
Vol. 5, 1971, p. 425-40.
6 10
Mikio Yamamoto et al., 'Summary of IIDA Re-
portA Case Report of Community Health
Care in a City in a Mountain District of
Japan', Bulletin of Juntendo University, School
of Health and Physical Education, Vol. 5,1962,
p. 24-41; Mikio Yamamoto, 'Chiiki hoken no
Susumekata ni Kansuru Ksatsu [Consider-
ation on the W a y to forward Community
Health Care]', Bulletin of Juntendo University,
School of Health and Physical Education,
Vol. 6, 1963, p. 72-82 (paper prepared for
the Special Lecture in the National Confer-
ence of The Japanese Society of Public
Health in 1963, Yokohama); Mikio Yama-
moto (ed.), Community Health Care and its
BackgroundA Case Report at the City of
lida, Nagano Prefecture, Yokohama, Yurindo
Shuppan C o . (English summary p. i-x), 1966;
Mikio Yamamoto (ed.), Evaluation of Com-
munity Health CareA Case Report of Com-
prehensive Community Health Care Project, at
Hiketa, Kagawa Prefecture, p . 484, Juntendo
University, Department of Public Health,
School of Health and Physical Education,
1967.
471
Edward S. Rogers, Mikio Yamamoto et al.,
' Ecological Associations of Mortality in Japan
and the United StatesA Factor Analytic
Study', in: M . Tachi and M . Muramatsu
(eds., Conveners of the Congress Symposium
N o . 1), Population Problem in the Pacific.
The Eleventh Pacific Science Congress, p . 167-
79, Tokyo, 1966.
8
Chikio Hayashi, 'Note on Multidimensional
Quantification of the Data Obtained by the
Method of Paired Comparison', Ann. Inst.
Statist. Math., Vol. 19,1967, p. 363-5; Chikio
Hayashi ('On the Prediction of Phenomena
from Qualitative Data and the Quantification
of Qualitative Data from the Mathematico-
Statistical Point of View'), Ann. Inst. Statist.
Math., Vol. 2, 1952, p. 93-6.
9
Mikio Yamamoto et al., Ecological Analysis on the
Health of the Japanese People: 'Report 1.
Life Expectancy at Birth and Standardized
Mortality Rate due to all Causes of Death',
J.J.PH., Vol. 17, N o . 11, 1970, p. 32; ' R e -
port 2. Growth', J.J.PH., Vol. 17, N o . 11,
1970, p. 33; 'Report 3. Cause Specific Stand-
ardized Rate', J.J.PH., Vol. 17, N o . 11,
1970, p. 34; 'Report 4. Age Specific Death
Rate', J.J.PH., Vol. 17, N o . 11, 1970,
p. 35; 'Report 6. Influence of Urbanization
Toward Health of the People', J.J.PH.,
Vol. 18, N o . 10, 1971, p. 166.
Mikio Yamamoto et al., 'Ecological Analysis on
the Health of the Japanese People: 'Report 5.
Climate', Journal of Japan Hygiene Associ-
ation, Vol. 26, 1971, p. 76.
11
Mikio Yamamoto et al.. Ecological Analysis on
the Health of the Japanese People: 'Report 7.
Nutrition', J.J. Human Ecology and Race
Hygiene, Vol. 37, N o . 6, 1971, p. 227-8;
'Report 10. Numerical Taxonomy of Pre-
fectures', / . / . Human Ecology and Race Hy-
giene, Vol. 38, N o . 6, 1972, p. 286-7;
'Report 12. Influence of Climate toward
Living Behavior', / . / . Human Ecology and
Race Hygiene, Vol. 39, N o . 6,1973, p. 186-7;
'Report 13. Comparison between 1965 and
1970', / . / . Human Ecology and Race Hygiene,
Vol. 40, N o . 6, 1974, p. 333-4.
12
Mikio Yamamoto et al., Ecological Analysis on
the Health of the Japanese People: 'Report 9.
Medical Facilities', Bulletin of the Population
Association of Japan, 1972, p. 6; 'Report 11.
Living Time', Bulletin of the Population As-
sociation of Japan, 1973'; 'Ecology of Death',
Bulletin of the Population Association of Japan,
1975.
 472
Hiroaki Terao, Kazue Yantada
Notes (continued)
13
Mikio Yamamoto et al., 'Reisai Heikinyomei no
Eikyosuru Shojoken [Various Circumstances
Influencing Life Expectancy at Birth]', Bull,
of the Population Association of Japan, 1970;
Mikio Y a m a m o t o et al., 'Nihon no Kekkaku
Shibo ni Eikyosuru Shoinshi ni Kansuru
KsatsuTahenryo Kaiseki [Consideration
on Various Factors influencing Deaths due to
Tuberculosis in Japan]', Bulletin Juntendo
University, School of Health and Physical Edu-
cation, Vol. 13, 1970, p . 44-54.
14
S. Kitagawa, ' Th e Classification of Cities from the
Viewpoint of Health by a Factor Analytic
Study of Health Indices', J.J.PH., Vol. 14,
1967, p . 889-905; Hatano Kyoko, 'Levels and
Mikio Yamamoto with Chikio Hayashi
Styles of Living and Health Indicators', The
Japanese Journal of Human Ecology and Race
Hygiene. Report 1, Vol. 38, 1972, p . 39-49;
Report 2, Vol. 38, 1972, p . 50-9.
15
Statistical Bureau, Ministry of Agriculture and
Forestry (ed.), Shokuryo Shohi Sogo Chosa
Hokoku [Report of Comprehensive Survey on
Food Consumption], 1968; Statistics, Of-
fice of the Prime Minister (ed.), Monthly
Report on the Retail Price Survey, N o . 173,
November 1966; Resources Bureau, Science
and Technology Agency (ed.), Standard
Tables of Food Consumption in Japan, 1963
(3rd rev. ed.).
 Patients and their resort
to health care
Attitudes towards the use of the medical
and sanitary services in Iran

Manouchehr Mohseni

Introduction

Illness is both a biological and a social phenomenon. It encompasses attitudes,

relationships, reactions, behaviour, meanings and techniques which enable the
members of a group to identify different illnesses, to take action accordingly and to
m a k e use of a body of knowledge in order to cope with the illness (Saunders, 1970).
W h e n society becomes aware of the problems raised by individual sickness it reacts
in different ways.
In recent publications concerning the use of medical and sanitary services in
the developing countries, the sociological aspect has often been placed in the fore-
ground. It has frequently been indicated that the use m a d e by an individual of the
medical and sanitary services is influenced in large measure by the extent of his
schooling, his socio-occupational category, age and place of abode (Coe, 1970).
Modifications in the socio-economic structure of the population will lead to changes
in attitudes and behaviour.
The data analysed in this article have been taken from a survey conducted
in 1975 by the Department of H u m a n Ecology of the University of Tehran 1 a m o n g
the inhabitants of the Saheli Province (Persian Gulf islands and coast) in the south
of Iran.* The purpose of that part of the survey dealt with here was to determine
attitudes towards the use of the medical and sanitary services. In this article w e shall
examine the relationships between levels of education, residence and age on the one
hand and, on the other, the variables involved in attitudes regarding the use of the
medical and sanitary services.

Manouchehr Mohseni is Professor of Sociology at the University of Tehran, School of Public

Health, P.O. Box 1310, Tehran (Iran). He has published a book on social demography in 1974,
one on medical sociology in 1975 and his book on general sociology has gone through three editions.
A contribution by him on sociological research in Iran can be found in this Journal, Vol. XXVIII,
No. 2 (1976).

Int. Soc. Sei. J., Vol. X X K , N o . 3, 1977

474 Manouchehr Mohseni

Methodology
The method employed consists in a comparative study of attitudes in matters of
health in rural and urban areas. The urban and the rural samples have been arranged
according to the size of the communities. It was expected that in both cases differ-
ences of behaviour and attitudes would be observed as between the small and the
large towns and the small and the large villages. O n the whole, however, the internal
variations within the categories proved either insignificant or irregular. There were
marked differences between urban and rural communities rather than within each of
those categories. Consequently the results are presented in the form of comparisons
between the urban and rural populations. Finally, the sample comprised 1,085 urban
households and 871 rural households3 selected at random. O u r data have been
analysed in terms of the way in which place of residence, age and level of education
affect the attitudes of the head of the household.4

Characteristics of the sample

T h e region is tropical. Because of the climate there are contrasts in the types of food-
stuffs produced. T h e staple foods are cereals. T h e quantity of animal proteins
consumed is generally less than the recognized need. Milk production is seasonal
because of the drought that lasts the greater part of the year. Cattle, which are
regarded as a capital asset, are rarely eaten. The inhabitants of the villages are mostly
farmers and derive their main income from growing cereals, plus some animal
husbandry. Most inhabitants of the towns have settled there recently. The high rates
of migration to and from the province are characteristic of the great migratory
movement from the countryside to the towns.
Table 1 shows the numerical and percentage breakdown of the 1956 heads of
household covered in our survey in terms of the characteristics selected. The average
age of the rural sample was 42.2 years, while 55.7 per cent were 44 years of age or less.
T h e average age of the urban sample was 40.3 years. The survey revealed an illiteracy
rate of 47.9 per cent a m o n g the town dwellers and 74.8 per cent a m o n g the rural
population, the level of education being higher in the urban areas. A s regards the
occupational distribution of the heads of household, in the rural areas 51.7 per cent
were farmers, while 30.2 per cent of the urban population were white-collar
workers. Nearly all those surveyed were married.

Socio-ecological differences

A s regards the level of health, variations are often to be found within the same
milieu. A distinction can be drawn between the physical milieu and the h u m a n
 The use of medical and sanitary services in Iran 475

T A B L E 1. Characteristics of the sample according to place of residence

Urban areas Rural areas

Characteristics
Number Percentage Number Percentage

Age (N = 1,085) (N = 8 7 1 )
24 and under 105 9.7 74 8.5
25-34 325 29.9 188 21.6
35-44 283 26.1 223 25.6
45-54 223 20.5 205 23.5
55-64 93 8.6 127 14.6
65 and over 56 5.2 54 6.2
Average 40.3 42.2
Standard deviation 16.4 13.7
/ = 16.763, P < 0 . 0 5

Education
Illiterate 520 47.9 652 74.8
Primary 395 36.4 199 22.9
Secondary 155 14.3 20 2.3
Higher 15 1.4 0 0.0
Socio-occupational category
Farmers 0 0.0 450 51.7
F a r m workers 0 0.0 138 15.8
Industrial workers 308 28.4 122 14.0
White-collar workers 328 30.2 38 4.4
Shopkeepers, craftsmen 242 22.3 43 4.9
Middle and higher management 55 5.0 0 0.0
Liberal professions 8 0.7 0 0.0
Others 94 8.7 52 6.0
Unemployed 50 4.7 28 3.2

Marital status
Unmarried 47 4.3 15 1.7
Married 1,016 93.6 831 95.4
Widower or divorced 22 2.1 25 2.9

milieu (Cantrelle, 1973). Factors like the climate, with its seasonal variations, would
be classed under physical milieu, while others, like the traditional treatment of the
sick, would c o m e under the h u m a n milieu. S o m e , as for example the food available,
concern both milieux at the same time.
Perception of the environment reflects an urban attitude; this is shown by the
data concerning occupation and education. Those w h o use the modern health
services usually c o m e from the non-agricultural trades and are particularly numerous
a m o n g the skilled occupations. In the rural areas there is also a strong positive
correlation between the users and the level of education, literacy, readership of
476 Manouchehr Mohseni

newspapers and the possession of modern industrial products. 57.2 per cent of the
non-users have not been to school and are illiterate, as against 41 per cent of the users.
Urbanization increases the d e m a n d for medical facilities. Industrialization
generates different ailments, a m o n g others mental illnesses and work accidents.
Traffic accidents, alcoholism and venereal diseases are also more current in large
towns than in rural areas.
During the last few years there have been large-scale migrations to the urban
areas (Planning Organization, 1976), which sets special problems for those planning
the health services (Mohseni, 1975). It is possible that the plans for improving health
conditions in rural areas will be abandoned temporarily because of the urgent needs
which are making themselves felt in urban areas. T h e scale of the migrations would
also have an effect on the type and size of the medical centres to be built in the future
and consequently on the cost of the health services. In rural areas there is a relation-
ship between the distance of the patient's h o m e from the hospital or health centre
on the one hand and the use of these services on the other.
A study of Table 2 shows wide divergences from one region to another. T h e
cause of these divergences must be sought in differences of infrastructure, there
being wide variations not only in the overall amount, but also in the very nature of
the medical facilities m a d e available to a population (Pelicier et ai, 1973).
Although fairly substantial progress has been m a d e during the last few
decades, the situation from the health point of view is still far from satisfactory. It is
very different in the urban areas where the medical facilities and personnel are
concentrated. It is in these areas, moreover, that m o r e systematic action is taken in
regard to antibacterial measures, insect pest control, sewage disposal and the pro-
vision of drinking water. In addition, the income derived from wages, which are
mainly distributed in the urban centres, enables the sick to obtain medical treatment.

T A B L E 2. The X2 criterion for the hypothetical variables (N= 1,956)

Independent Dependent Degrees of ++ + ++ Thresholds of

variables variables"1- freedom X3 C significance

Age A 25 44,506 0.144 P <0.01

Education A 15 163,553 0.268 P < 0.001
Community A 5 503,463 0.439 P < 0.001
Age B 10 21,041 0.104 P <0.05
Education B 9 69,784 0.186 P < 0.001
Community B 2 250,797 0.340 P < 0.001
+
A = Reaction to illness.
B = Attitude towards availability of medical and sanitary services.
%
++ x* ^" -f
A 2
+++. C = / 2X
' X +N
 The use of medical and sanitary services in Iran 477

The number of inhabitants per doctor is an approximate index of the adequacy

of the medical and sanitary services. In rural areas the situation is m u c h more serious
than thefiguresreveal. The doctors tend to remain in urban areas, since the d e m a n d
in these areas, where the fees are usually m u c h higher, has not yet been satisfied,
with the result that there are scarcely any doctors left to work in the rural areas.
At the national level the medical density is very low. There is one doctor for
707 inhabitants in the region of Tehran and one for every 7,570 inhabitants in the
province surveyed. Naturally the extent to which a region is equipped with adequate
health services cannot be determined from one series of statistics alone; account
must also be taken of the number of other sanitary agencies, and of the organization
and quality of those services.
The survey shows that the n u m b e r of medical consultations per a n n u m per
person is 1.2 for the rural population as against 2.7 for the inhabitants of the urban
areas. The shortage of trained personnel, their unequal distribution over the country
and the unco-ordinated activities of a number of health institutions with differing
aims have m a d e it difficult and even impossible to set up an effective medical and
sanitary network (IRPSE, 1974).
The percentage of fatalistic replies diminishes as the degree of urbanization,
the level of education and the size of income increase; it is relatively low a m o n g
those people w h o have a certain control over the demographic elements of their
existence. Complete fatalism is only to be found a m o n g those groups which are the
leastfittedto practice modern medicine, which have the least need to resort to it and
the least chance offindingmedical and sanitary services within reach.

Traditional and modern medicine

Attitudes regarding the medical and sanitary services cannot be discussed without a
profound knowledge of the traditional medical system.
M a n ' sfirstreaction to sickness is to seek the cause and find the cure. In Iran,
as in m a n y countries, both modern and traditional systems of medicine are to be
found (Rogers et al., 1975). T h e traditional system is less apparent and is often
neglected by those in charge of the medical and sanitary services. Yet it enjoys
greater favour and is resorted to m o r e often than the modern system.
W h e n individuals are asked what they think of traditional medicine, most of
the urban lite and a substantial percentage of the population as a whole are apt to
say that it is not justified. This opinion is particularly frequent a m o n g people w h o
have been to school.
According to Okediji (1973) traditional medicine is not a haphazard medley
of meaningless customs; it can be viewed as an institutionalized structure of social
relations and a cultural model of behaviour and thought. T h e mutual links and
interaction of sick and healthy individuals, as well as their respect for those w h o are
478 Manouchehr Mohseni

legitimately held to be competent healers and their dependence on those healers,

are an essential factor. Also worth mentioning, perhaps, are the methods of treating
diseases and the precautions taken to avoid disease, on the one hand, and, on the
other, the concepts of a natural world and a supernatural world which underlie
the beliefs held concerning the appearance of the illness, the possibility of treating
it and the preservation of health. If modern medicine is resorted to relatively little
by the less educated, those born in the country or those w h o belong to the first
generation to attain more comfortable standards of living, it is not because they
refuse to be treated but because of the difficulty most of them find in coping with,
and above all assimilating, social and technological innovations. The members of
these groups are almost as anxious to m a k e use of modern health services as the
others are, but they cannot d o so unless those services are presented to them in such
a w a y as to minimize the obstacle represented by innovation and unless they are
k n o w n and accessible to a large enough public.
In a traditional society every individual is given a status and a role which he
must accept because they have beenfixedby tradition since time immemorial. This
social position does not depend upon what the individual in question does, but
upon what the group 'knows' about him, about what he has and about what his
parents are. Such a prescription allows n o freedom of choice in major decisions.
W h a t the society expects from the individual is clearly defined and by conferring
upon him his status and his role it expects him to abide by them and to adopt the
behaviour which is implicitly present to him. O n the other hand an industrial
society, as Mattelart (1967) has stressed, is subject to conscious and voluntary
transformation. The evergrowing application of science to all spheres of social life
makes it essential that change should be considered as a normal phenomenon.
Hence the values relating to medicine are n o longer conferred by medical tradition
and accepted passively, but are modelled on those criteria of reason and effectiveness
which tend to take over in the organization of society and eventually in the life of
the individual.
However, despite the existence of modern health services, which m a n y people
are beginning to accept after finding that they are more effective in treating illnesses,
some traditional medical beliefs and practices still survive. Traditional medicine is
practised by healers, w h o usually enjoy great social prestige and indulge in mystical
practices. They m a y perform minor operations. Traditional midwives, too, are to be
found in nearly all the villages. It is estimated that 85 per cent of all births still take
place with the aid of the traditional midwives. The attitude of these traditional
midwives towards the official health services is usually one of opposition. They
still feel that they are playing a social role rather than practising a profession. In
addition to confinements they carry out other health activities. Their incomes are
modest, but they enjoy great prestige in the community. In Senegal the marabout,
whose office is hereditary, is both a healer and a religious chief. In Turkey there
are several kinds of healers: some give injections, others perform circumcisions,
 The use of medical and sanitary services in Iran 4,19

others practice bleeding and others are pullers of teeth (Fendall, 1972).
In rural areas sickness is still regarded as a curse of nature to which one must
resign oneself; people have always seen children dying in large numbers and there
is nothing to suggest that it could be otherwise (Morichau-Beauchant, 1967). Indeed,
the rural population of Iran has always been ruled by the belief that the important
matters, such as death, are out of man's control. Such a belief easily leads not only
to an acceptance of destiny but also to a fear of disturbing its course. The fact
that 42 per cent of the rural population are apprehensive of modern medical and
sanitary practices, is precisely because they suspect that they m a y be effective. The
majority of the rural population still trusts in the traditional medicine, though also
resorting to modern medicine.
A s Saunders (1970) has emphasized, every individual derives his knowledge
of medicine from a number of separate sources: medical customs, popular medicine
and modern medicine. For any given ailment these sources m a y be used by the
patient in whatever order seems the most appropriate to himself or to those w h o are
giving him advice or trying to help him in one w a y or another. The establishment of
modern medical and sanitary services disrupts the traditional system. That is w h y
differences of attitude are bound up with socio-economic conditions. The spectacular
results obtainable by modern medicine will open up new prospects. Popular trust
will be established all the m o r e speedily if the means employed do not modify the
w a y of living of the individuals and if the latter are not taken away from their
original surroundings. Morichau-Beauchant (1967) points out that preventative
measures are of less evident value than those aimed at obtaining a rapid cure of
sickness. Health education helps to reinforce the effectiveness of the medical and
sanitary services. It is for this reason that health education was originally conceived
and organized. Medical services cannot function effectively unless the whole of the
population which will be using them feel themselves to be directly concerned
(Vellas, 1972).

Socio-economic factors

Table 2 shows a very close correlation between socio-demographic variables and the
reaction to illness. The better educated choose the hospital, while the less educated
prefer to m a k e use of the traditional services. Apart from the place of residence,
perhaps no other social variable has been associated more often with differences of
attitude in regard to public health than education. Medical consumption increases
with the level of education. Thus a significant correlation has been noted between
female education and knowledge of contraceptives.
The data relating to medical attention show that certain categories of care are
demanded by persons belonging to the highest socio-occupational categories. The
largest users of the medical and sanitary services are the higher- and middle-
480 Manouchehr Mohseni

management class. Those using them the least are the farm workers and farmers.
The socio-occupational category is essentially defined by the occupation of the head
of the household and is m a d e up of a number of components: social milieu, level of
education and cultural attitudes. Depending on socio-occupational status, medical
consumption m a y be as m u c h as twice as high as it would be otherwise. In Belgium,
on the other hand, the Deurne study (Klein-Beaupin et al., 1974), reached the
conclusion that the effect of income was difficult to determine because it seldom acts
in isolation. The levels of consumption vary not only according to demographic and
economic-social criteria but also according to geographical criteria. The influence
of socio-occupational category on the consumption of medical services is in any case
m a d e up of a combination of several contributory factors, apart from income, such
as type of work, level of education and hence attitudes towards medicine.
In Iran there is often a close relationship between the level of education and,
in the urban areas at any rate, social status, income and occupation. This was
particularly true in the region under study. O f course other factors than the purely
socio-occupational also help to explain the differences in the range of consumption:
for example, medical care is less easily obtained in the country than in the town, the
socio-occupational categorization m a y conceal differences of income, etc. It is none
the less true that there are real differences in socio-occupational behaviour. M o r e -
over, while there is no exact correlation between mortality rates and level of medical
consumption, there is no fundamental contradiction between them, which confirms
the specific influence of the socio-occupational category on medical consumption,
regardless of whether the latter is the result of real or imagined sickness.
The changes in the population growth rate will lead to changes in the age
pyramid that will affect d e m a n d for health services. The age of individuals has a
very marked effect on their consumption; thefirstand the last years of life are those
of the greatest vulnerability and, usually, of the largest medical consumption
(Pelicier et al., 1973). O n the other hand, a higher age level m a y well indicate a less
favourable attitude towards modern medicine. This relationship is probably affected
by a socio-economic factor. The cultural factor also goes in combination with the
demographic factor. At the present time there is relative underconsumption by old
people (i.e. in relation to their needs), due to the fact that they reached maturity
before the advent of modern medicine and are still distrustful of it. The growth of
illnesses and infirmities a m o n g populations accustomed to modern medical care
from their childhood days is beginning to be reflected in a substantial increase in the
use they m a k e of the medical and sanitary services.

Conclusion

There is strong confirmation of the hypothesis of a link between non-traditional

attitudes towards medicine, on the one hand, and contact with the urban way of
 The use of medical and sanitary services in Iran 481

living on the other. Education has an immediate effect upon attitudes towards
modern medicine. Educated people are easy to inform by means of brochures,
magazines, pamphlets, etc. But above all education makes people more receptive
to new ideas and practices. At the same time differences in socio-economic conditions
affect not only the h u m a n milieu; they are also reflected in morbidity and mortality
rates (Okediji, 1973). The inhabitants of rural areas are less healthy than those of
urban areas. This disparity cannot be explained solely by differences in socio-
economic conditions; it is also based on knowledge and attitudes with regard to
public health and the use of medical services.
The effective consumption of medical care is still far removed from the needs;
thefinancialresources available are inadequate and the health education of the sick
varies greatly. N o t all individuals are equally aware of their health needs, while the
existing technical resources in the form of medical personnel or hospital facilities
cannot cope with the needs.
O n e particular problem of the region in question is that of knowledge about
public health. The individual should take the initiative in improving his o w n health
by seeking information from the health centres; such information would enable him
to understand the connection between bad hygienic habits and bad health. N o t only
does health education play an essential role in the prevention of illness; it also helps
to overcome the resistance of individuals and groups to modern medicine and
encourages the population to co-operate actively in carrying out the public health
programmes. Excellent opportunities for providing the w o m e n of a community
with health instruction occur when they take their children to the local health centres
where integrated preventive and curative services aie provided (Unicef, 1967).
W h e n an innovation is of major proportions and upsets earlier ways of
therapeutical reasoning, it sometimes proves difficult to incorporate into the existing
structures. Health information and education play a vital role by encouraging
individuals to observe a number of rules that determine psychosomatic equilibrium.
Indeed, modern means of information should be used for the health training of the
masses.
Changes in hygienic habits should not be imposed by the authorities, even
when such a measure would be in the interests of the community. Such a change
must be in keeping with the preoccupations felt by the individuals concerned. A s for
the social determinants of behaviour, there is a relationship between the individual
demand for space and the needs of the community. W h a t is wrong with the great
urban developments is not their size, but their faulty structure. These structures must
be in keeping with the various levels of social integration and with the different
functions which stem from them. A balance must be sought between the various
demographic, cultural and economic components and differing requirements that
result from them.
[Translated from French]
 482 Manouchehr Mohseni

Notes

1 3
I wish to thank Professors G . H . Jalali and
S. Hedayat, as well as m y colleagues D . Kyani
Manesh, F . Rouhani, A . Ramezanpoor and
M . Omidfar for their valuable contribution
to the preparation of this article.
2
The research reported on here wasfinancedby the
Faculty of Public Health of the University of
Tehran.
The size of the sample was calculated as follows:
" = -d*
4
The household may consist solely of related persons
or of people having no ties of relationship
between them, or of a combination of the
two. A head of household is the person w h o
is recognized as such by the members of the
household.

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National Development Plan. In: Ominde and blique, Vol. I, p. 102-9. Paris, Dunod.
Epoeu (eds.), Population Growth and Econ-
 Traditional and modern health care:
an appraisal of complementarity*

Peter Kong-ming New

Introduction
Until recently, medical sociologists and anthropologists have investigated the
phenomenon of traditional and modern medicine from separate poles. Those w h o
are interested in health care in Western settings have concentrated more on the
modern medicine approach, while those studying other cultures have stressed the
traditional and folk medicines. A third group has concentrated on the health care
systems. Since data on the macro-level are fairly reliable from Western nations, the
last group has utilized available data based mainly on patients seeing Western-
trained physicians. There are exceptional investigators w h o recognize that persons
seeking health care d o not categorize their search for appropriate healers in neat
bundles. Nevertheless, it is very convenient for investigators to work with existing
data and this usually means ignoring the role of traditional and folk medicines in
Western societies.
Increasingly, however, sociologists, anthropologists and even physicians, are
beginning to join forces to investigate all facets of traditional and Western medicines.
In particular, they are concerned with several issues: First, do traditional and modern
medicines coexist in a single cultural setting? H o w do they operate? D o patients seek
out both traditional, folk, healers as well as Western-trained physicians? Second,

Peter Kong-ming New is Professor ofSociobgy at the Department of Behavioral Science, University
of Toronto, 21 St Joseph St, Toronto, Ontario M55 1A1. Associate editor of Inquiry and H u m a n
Organization and formerly also o/Sociological Quarterly he has published some seventy articles
and six chapters in various books. He is chair-elect of the Medical Sociology Section of the American
Sociological Association.

* Parts of this article were presented at the Third In-

ternational Conference on Social Science and
Medicine, Elsinore, Denmark, August 1972,
under the title, 'Health Advice: Health
Care=Traditional Healers: Western Trained
Physicians?' Professor Reginaldo Z . de C a m -
pos, Faculty of Medicine, University of
Campinas, Brazil, shared many of his ideas
with m e , and Professor Richard M . Hessler,
School of Medicine, University of Missouri,
United States, m a d e m a n y valuable sugges-
tions on earlier drafts. I a m grateful for their
views.
Int. Soc. Set. J., Vol. X X I X , N o . 3, 1977
484 Peter Kong-ming New

can both traditional and Western medicine function in a single setting? Finally, at the
national level, what are the policy implications?
The development of private and public health insurance schemes in most
countries has been predicated o n the fact that Western medicines, presumably m o r e
scientific, are m o r e efficacious for patients. Thus, patients w h o see physicians, use
hospital-based facilities, and take Western drugs, are the ones w h o are covered by
these plans. Those w h o utilize traditional and folk medicines have themselves to pay
for their services. In Canada, for instance, it is only relatively recently that users of
chiropractic services in half of the provinces are covered by various provincial
health schemes, and even there, s o m e of the provincial health plans cover only
limited services. T h e manner in which the third party payments are established
implies that Western medicines are approved. In most Western or industrialized
societies, the prevailing view is that patients w h o are ill will enter into the orbit
dominated by physicians. A s Leslie (1976, p. 357) has pointed out, this is a mistaken
notion:

In the United States and other industrial countries, laymen and specialists assume that a
single cosmopolitan medical system exists, with comprehensive jurisdiction in all matters of
health: a hierarchy of paramedical specialists dominated by physicians; standard thera-
peutic techniques and ways of generating new skills and knowledge. In fact, the medical
system is a pluralistic network of different kinds of physicians, dentists, clinical psychol-
ogists, chiropractors, health food experts, yoga teachers, spirit curers, druggists, Chinese
herbalists, and so on. The health concepts of a Puerto Rican worker in N e w York City,
the curers he consults and the therapies he receives, differ from those of the Chinese laun-
dryman or the Jewish clerk. They in turn differ from the middle class believers in
Christian Science or logical positivism.

In order to discuss some of these issues, it will be necessary to view health care from
either the micro- or the macro-perspectives. O n the micro-level, these social psycho-
logical components of health care need to be considered: W h y d o persons seek
health care? W h a t types of health providers deliver care at appropriate times for a
person's needs? O n the macro-level, these health policies questions need to be
examined: In any nation, what existing policies encourage or inhibit the meeting of
these needs? In a recent paper, Bynder and N e w (1976, p. 49) m a d e this statement
regarding a need to broaden the focus of studies of disabilities from a narrow
micro-level to a m o r e macro-level:

The significance of the study of the politics of disability by sociologists can be illustrated by
analyzing the consequences of federal cuts in rehabilitation monies. W h e n federal funding
slackens, then it does not matter whether M r Brown or Mrs Jones are 'deviant' or not,
they are not going to be treated. The more limited socio-psychological concepts in sociology
cannot compete adequately with the more macro-structural concepts that occur on policy
levels.
 Traditional and modern health care 485

Although this article will not deal with disability research, I will review studies which
deal with the nature of patient-healer interaction in different societal settings at a
more micro-level. Then I will consider whether traditional and Western medicines
can coexist in different cultural and national settings. M y view is that too often, in
our zeal to propagate Western medicine, w e ignore the positive functions served by
traditional healers in all societies. Further, w e ignore the political and economic
consequences if traditional medicines were to be completely eliminated.
Recently, the World Health Organization (Newell, 1975) invited a group of
physicians to discuss their personal experiences in providing health care to the people
in different nations. Although the authors of papers described their successes in
various national or local programmes, Newell commented: 'In all these societies,
before the changes began, there w a s always something or someone dealing with
primary health care' (Newell, 1975, p. 192). Indeed, different societies have their
forms of indigenous health care providers for their people. However, as modern
medicine became available, the seemingly more efficacious means of providing
health care pushed aside the indigenous medicines. Yet, folk medicine has continued
to persist in all cultures, leading investigators to examine the significance of the
existence of the 'dual system' in health care.
For instance, Maclean (1971) examined the use of Nigerian folk practitioners
where Western medicine was also available. She contrasted the m o d e of c o m m u n i -
cation between the Western patient and his physician with a Nigerian patient w h o
might have gone to the same Western physician. The different meanings attached to
such encounters by patients from different socio-economic and cultural backgrounds
would lead some patients to seek out m o r e compatible providers.
Where dual systems of health care exist, it m a y be argued that the more
scientific orientation of the providers should certainly be favoured over the 'magical'
claims of the folk practitioners. However, as Maclean (1966), Press (1969), w h o
studied dual uses in Bogota, and Lieban (1976) w h o studied the same problem in
C e b u City, in the Philippines, have indicated, this is not the case. Health consumers
in different cultures still persist in going to folk healers. I begin here with a consider-
ation of the reasons persons seek care. Then I will consider the implications of these
findings in the light of some of the national policies of attempting to integrate
tradition medicine with Western medicine.

Magic and science in healing

Implicit in the magic versus science reasoning is that the consumers w h o subscribe
to the 'magical' powers of healing will gradually shed that belief and m o v e into the
scientific sector when they understand the efficacy of Western medicine. Magic and
science are seen as competing and sometimes even complementary beliefs
(Steckert, 1970).
486 Peler Kong-ming New

In an earlier study on the w a y magic and science work in Western Y u n n a n ,

H s u (1955) described h o w traditional healers and Western-trained physicians had
to work side by side to eradicate a cholera epidemic rampant at that time. Because
the Chinese did not understand the effectiveness of Western medicine, more tra-
ditional healing methods also had to be used. H s u went on to say that if the native
Chinese were brought out of his surroundings, it was more than likely that he would
adopt Western methods of treatment. M o r e recent studies have shown that the 'dual
system' can and does exist side by side. Leslie (1976) and U d u p a (1975) have shown
that Ayurvedic and Unani medicines, in existence for centuries in India, are based
on reasonable physiological assumptions and are still being taught in colleges in
India at present. Maclean (1971) also found that Yoruba folk medicines rested on
fairly complex philosophies. Even though they had access to Western hospitals and
clinics, m a n y Yorubas used these facilities for selective illnesses (Maclean, 1969).
Even though patients from more educated families utilize native medicines less, they
still maintain these uses. Press (1969, p. 216) suggests that 'the phenomenon of dual
use is a complex one and cannot be understood in simple terms of "pragmatism",
"appropriateness" or "acculturation" '. O n e needs to examine the manner in which
patients evaluate a whole host of factors, beginning with their beliefs in the efficacy
of treatment offered by a variety of healers and their relationship to the healers
themselves.

Alternate pathways to health care

W h e n beliefs in magic and science compete in the same society, there should be
alternative ways of examining pathways to health care. First, it is important to
recognize that health consumers take m a n y different paths to reach the goal of
'relief of suffering, however that is defined by the health consumer. This puts the
situation in a slightly broader perspective than saying that the goal is seeing a
physician, which is the more dominant perspective. T h e latter view has been greatly
influenced by Parsons (1951 and 1975) w h o suggests that a person has an obligation
to seek care from the most qualified person, w h o in the Western world is certainly
the physician. The shortcomings of the Parsonian concept of the sick role have been
criticized by Gallagher (1976) on three major points: First, the deviance conception
fails to account for patient behaviour in chronic somatic illness, which is long term
rather than consisting of acute, short term, episodes; second, it fails to account for
preventive health care or health maintenance, as an element of normative lay
conduct and of the professional responsibility of the physician; and third, it presents
a relatively undifferentiated picture of the social structure of health carethe
physician's responsibilities in different social settings vary a great deal.
Pathways to health care should be seen as completely 'open' where the end
result of the seeker is to obtain relief. T o be sure, beliefs regarding magic or science
 Traditional and modern health care 487

m a y determine which path a person takes, but magic and science m a y also coexist in
the person's o w n belief system, with little contradiction (Press, 1969). A person
seeking health care m a y take any number of paths, of which the following represent
only some configurations: (a) he m a y start out by seeking advice from the lay referral
system and end with health care in the professional referral system, along the lines
which Freidson (1961) has suggested; (b) he m a y start with advice from lay persons
w h o then m a y suggest that he take the 'deviant' paths to other traditional healers,
for either advice or care; this person then m a y never enter the orbit of the professional
(i.e. Western-trained) physician; (c) he m a y enter the professional (Western phys-
ician) system butfindlittle or n o relief and seek the services of traditional healers;
or (d) he m a y seek the services of professional and traditional healers simultaneously,
especially when he perceives that one is not able to d o anything for him. There m a y
yet be afifthway; the person m a y m o v e back and forth between Western and
traditional healers.
In the movements suggested above, several factors are undoubtedly important
in the person's calculations as to which healer he should seek out. Accessibility is one
such factor. This m a y not only be geographical but 'knowledge' and 'awareness'
accessibility as well. Persons w h o are not in the network of spiritual healers or
curanderos m a y not even k n o w that such persons exist. The more intriguing question
is whether, if the person does k n o w of their existence, would he utilize them and for
what purpose? Appropriateness of the occasion is equally important, and this also
implies correct timing. Certain traditional healers are k n o w n to offer preventive
services, such as warding off the evil eye or making up herbal teas to prevent illness.
T o be sure, whether the person seeks out or stays in particular orbits m a y be
determined by his belief in the efficacy of the treatment he receives, or m a y depend
on his belief in the 'magic v. science' orientation. Nevertheless, he must see some
relationship to the immediate relief he seeks.
Second, the elements of legitimacy and respectability in seeking health care
need to be considered. Koos(1954) mentions that, for certain people, suffering from
backache is not unusual. If a person were to seek relief, he would be derided because
'everyone has a backache once in a while'. Although society in general m a y place a
high value on seeking health care, for that person and his immediate circle, seeking
care would be defined as non-legitimate. F r o m w h o m should such a person seek
health care? K o o s ' findings imply that friends of the health consumer m a y define
which provider is deemed 'respectable'. For the stereotyped middle-class suburban
house-wife, going to a physician is perfectly respectable, but going to a curandero
would not be. If she took prescribed drugs, this would befine,but if certain herbal
teas were found in the kitchen cabinet, she m a y have to explain and rationalize.
488 Peter Kong-ming New

Health-seeking behaviour
If health consumers are able to secure the services of traditional healers, this means
that they must be accessible. However, from a personal motivation standpoint, it
does not matter m u c h h o w accessible the providers of care are if the consumer does
not intend to refer to them. Thus far, there is insufficient information on 'triggers'
which send consumers to traditional healers as against Western-trained physicians,
since deviants from the system seldom volunteer information on their behaviour
(New and Priest, 1968; Zola, 19726). With the exception of Maclean (1966),
Press (1969), and Lieban (1976), very few systematic attempts have been m a d e to
discover h o w consumers seek advice and health services from traditional healers,
Anthropologists and other investigators are only beginning to answer certain
relevant questions.
First, when does a consumer seek the services of traditional healers? Just as
there are m a n y specialists in the medical world, there are also healers w h o perform
different preventive and curative functions (Leslie, 1976, p. 358-60). S o m e m a y be
able to help a person w h o has psychiatric or physical problems (Kapur, 1976;
Kiev, 1964; Kleinman, 1976). H o w sophisticated are consumers about which
traditional healers they should choose? Such questions are asked of patients w h o go
to medical specialists, but they are equally important w h e n one is dealing with
traditional healers.
There is also a need to establish the appropriate time during the course of an
illness w h e n the consumer seeks services from traditional healers. M c D o w e l l (1950),
for instance, noted that m a n y patients consulted osteopaths because they were
dissatisfied with physicians or because they found the latter not personal enough in
dealing with patients. H o (1975), an osteopath, recently reported on patients w h o
actually got relief through acupuncture treatment from him after they had consulted
physicians. Lewis, a physician, reported on similar relief in patients w h o went to
physicians for acupuncture treatments in a medical clinic (Lewis et al., 1976).
Central to the whole question of w h e n a person seeks health care is the nature
of beliefs about health and illness (Zola, 1966 and 1972a). M u c h has been written
about these beliefs from the standpoint of particular cultural groups (Hessler et al.,
1975) or even from subcultures of dominant groups, such as 'working class beliefs'
or 'middle class beliefs', but little is k n o w n of the part superstition plays in mobilizing
a person to seek health care. Similarly, little attempt has been m a d e tofindout h o w
an individual's beliefs in the efficacy of care offered by traditional healers become
modified when he is introduced to other types of care, or h o w he m a y revert to
earlier beliefs to deal with what he considers to be the inexplicable continuation of
unrelieved symptoms.
Second, from w h o m does a health consumer seek care? A great deal is k n o w n
about the health care rendered by physicians, but even though data have been
obtained from a small group of non-physicians, such as chiropractors (Cowie and
 Traditional and modern health care 489

Roebuck, 1975; Wardwell, 1958), osteopaths ( N e w , 1958), Christian Scientists, etc.,

there is still very little information about the care they render. M y colleagues are
currently undertaking a three-year study of Canadian chiropractors to partially
remedy this lack of knowledge. F r o m some of the preliminary information they have
gathered thus far, when or h o w patients seek chiropractic care m a y be determined
by the limitations placed by the provincial health insurance plans, an economic
consideration. This raises an important question: If there were no financial
constraints, would these same patients use their services even more?
Third, w h e n a consumer goes to a traditional healer, does he actually seek
health advice or does he want a cure? This, too, is a difficult question, since 'advice'
and 'cure' often cannot easily be separated. A t the simplest level, I consider advice
as similar to counsel, but persons w h o seek counsel also want a cure, as in the case
of genetic counselling (Fraser, 1976) Nevertheless, m u c h health servicing can be
categorized as advice and m a n y individuals have health problems which d o not
require in-hospital care. If that is the case, d o traditional healers offer adequate
intermediate health advice along this pathway to health care?
Fourth, what claims d o traditional healers m a k e to the consumers w h o seek
their servicespurely advice-giving or also curative? Just as consumers harbour
their beliefs in the efficacy of certain treatments, so traditional healers (and, for that
matter, even Western-trained physicians) must hold their beliefs as well. In certain
interviews with traditional healers, they often mention that they can help only to a
certain extent, after which physicians must take over ( N e w and C o n n , 1969; N e w ,
Ricci and Hessler, 1971; Twaddle and Hessler, 1977 p. 143-50). This is especially
true of spiritual healers, the police, bartenders, or Christian Scientists w h o place
great credance in G o d and His Power, as The healer. Certainly, A . T . Still, the
founder of osteopathy, also placed faith in G o d , although he attributed cures solely
to osteopathy ( N e w , 1958). A t the other extreme, some physicians are great believers
in Krebiozan, for instance, as the cure for cancer (Lasagna, 1962, p. 256).
Even though healers feel they have something to offer the consumers, little
is k n o w n on h o w they go about gaining and retaining legitimacy and respectability,
especially in places where medicine predominates. Possibly, the traditional healers
give their patients a sense of 'absoluteness' in their ability to deal with illness, as
implied in the findings of Shuval et al. (1970). They find that, although the
Moroccans and the Kurds w h o utilize the K u p a t Holim clinic in Israel have a high
orientation towards traditional health practices, they also (Shuval et al., 1970,
p. 177):

express high confidence in the absolute objectivity and exactness of medical science and
seem to be less aware than the Europeans of the limitations of the professions of the guess-
work that goes into a considerable measure of medical diagnosis and therapy.
In a similar vein, Maclean (1966, p. 139) mentions that Ibadan patients consult the
local healers,
490 Peter Kong-ming New

in a reassuring atmosphere, which comes from a familiar situation in which each person
knows his role and its probable outcome. Patient and healer alike share their confidence in
the supreme power of the word, the appropriate word, uttered with authority as
accompaniment to the correct ritual procedure.... If his disease has indeed been largely
influenced by his mental state, the ritual procedure will undoubtedly contribute to recovery.

Following Shuval and Maclean, a hypothesis can be suggested: Those consumers

w h o are uncomfortable with ambiguous answers about the cause of their illness turn
to traditional healers w h o are m o r e positive in their answers If that is the case, then
traditional healers m a y have greater appeal to consumers at certain points during
the course of their illness.
Finally, what happens w h e n all else fails, i.e. the health consumer does not
find any suitable healer? In the Western world, groups of'health agnostics' are n o w
appearing. They d o not necessarily believe in traditional medicine, but d o not feel
modern medicine helps. S o m e have banded together to help each other. Alcoholics
A n o n y m o u s was one of thefirstself-help groups formed in the 1930s and m o r e
recently other 'anonymous' groups have modelled themselves after it. W o m e n ' s
health collectives have also been formed to promote mutual learning about care
ignored by physicians (Boston W o m e n ' s Health Collective, 1976), as an extension
of the w o m e n ' s liberation movements. H o w long they will function remains to be
seen. Nevertheless, these self-help groups represent general disenchantment with
health care as currently provided (Borman, 1975; B o r m a n and Lieberman,
1976).
In this examination of the potential pathways a person m a y take to seek out
the appropriate health provider, I suggest that a particular blend of chemistry has
to take place. The health consumer has to define for himself whether he is ill a n d
h o w he is going to secure s o m e relief. A s Leslie (1976) has shown, laymen and pro-
fessionals m a k e an unwarranted assumption that a single cosmopolitan medical
system exists. A t the micro-level, anthropologists have found that health consumers
respond to illness in the cultural context. Gould (1977, p. 497), for instance, mentions
that 'a given illness m a y fall within the ambit of what is defined in a culture as the
realm of divine ordination and m a y , therefore, be singled out for special super-
natural treatment'. Logan (1977) and Hessler et al. (1975) have shown that beliefs
in the humoral medicines a m o n g Guatemalans and Chinese-Americans, continue to
persist and this affects the manner in which they seek out health providers and take
certain hot or cold foods depending on their illness. W h e n persons are sick (Leslie,
1977, p. 517):

They are less concerned with whether therapy is indigenous or foreign, traditional or
modern, than with how much it will cost, whether or not it will work, how long it will take,
and whether the physician will treat them in a sympathetic manner. They are also often
concerned with the ways that different kinds of diagnosis and treatment attribute illness to a
moralflawof the patient or some other person, or to forces for which they are not respon-
 Traditional and modern health cafe 491

sible. In these respects, laymen everywhere are pretty m u c h alike. They differ only in the
knowledge they draw upon to resolve these issues, and the kinds of specialists they have
access to.

Integration of traditional and Western medicines

Whereas earlier studies in the use of traditional and folk medicines were focused on
consumers of these forms of medicines, with m u c h less emphasis on the structural
components of the health system, social scientists are n o w m u c h m o r e concerned
with the totality. Studies by anthropologists, especially, indicate that traditional
medicines do persist even though the health consumer has access to Western
medicines which are deemed m o r e scientific. A s m o r e countries adopt various forms
of private and public health insurance schemes, it would seem logical that traditional
medicines would not be used as m u c h . There is, of course, a fallacy in reasoning this
way, in that ' w e characteristically look at our o w n and other medical systems from a
statist perspective, and one biased by the categories and professional interests of
cosmopolitan medicine' (Leslie, 1977, p, 516). In so doing, w e m a k e little attempt to
discover the extent to which traditional medicines are used. It follows, then, that
in most countries or cultures, no effort is m a d e to integrate the two forms of medicine
so that the health consumer would benefit. If anything, w h e n traditional practitioners
would like to integrate into the health system, as in H o n g K o n g (Lee, 1975), the law
prevents them from interacting with the dominant group. This is certainly true in
most Western countries, which allow other health professionals, such as chiro-
practors or osteopaths, to practise; yet, they will not allow them full rights.
W h e n one discusses the question of the integration of traditional and Western
medicines, the central issue is, ' W h o benefits?' T h e obvious answer is the patient,
but the current bureaucratic and dominant professions, such as medicine, would
have to yield a great deal of control. A s health systems n o w stand, with basically but
a single w a y of delivering health care, its proponents can easily argue that w e can
carry out health promotion and m a k e everyone change his or her health behaviour.
Novarro (1975, p. 361) is very sceptical of this approach:

I believe that the greatest potential for improving the health of our citizens is not primarily
through changes in the behaviour of individuals, but primarily through changes in the
patterns of control, structures, and behaviour of our economic and political system. The
latter would lead to the former. But the reverse is not possible.

W h a t Novarro suggests is being attempted in s o m e of the countries, as they seek

alternate ways of integrating traditional and Western medicines A s one can readily
appreciate, the most difficult task is to change the entire political or health structure
to accommodate the dual use of these medicines I shall briefly review what attempts
are being m a d e in Africa and Asia.
492 Peter Kong-ming New

In reviewing what has happened in Africa, Dunlop (1975) mentions that

through national policies a country could legislate as illegal the practice of tra-
ditional medicine. (This certainly occurred in China in the 1930s w h e n Western-
trained physicians tried to m a k e it illegal for the traditional practitioners to exist
(Croizier, 1968, 1973 and 1976).) The other policy alternatives are the legalization
of traditional healers or their informal tacit recognition through training, research,
recognition of complementary services provided and informal communication
linkage and referrals between traditional and Western-trained health personnel. In
the nine African nations examined (Liberia, G h a n a , M a b ' , Nigeria, Ethiopia,
U g a n d a , Zaire, Botswana and the United Republic of Tanzania), Dunlop found
that all tacitly recognize complementary services provided by traditional healers,
andfive(Ghana, Mali, Nigeria, Zaire and Botswana) are considering legalization of
traditional healers. Although these nations m a y be moving towards a pluralistic
form of health care delivery, I feel the greatest obstacle m a y be the unwillingness
on the part of health personnel trained by the former colonial powers to yield their
prerogatives. In discussing the use of health assistants in Kenya, for example,
T h o m a s (1974 and 1975) found strong remnants of the colonial antecedents and
there was still the lack of integration of services, traditional and Western.
Leslie, long a student of Ayurvedic and Unani medicines in India, has given
ample evidence of integration of these with Western medicine (Leslie, 1976,1977).
There are a large number of colleges which teach Ayurvedic medicine, and s o m e
have achieved distinctions similar to those of Western medical colleges in India.
In 1972, the State boards of indigenous medicine had registered 257,000 prac-
titioners, of w h o m 93,000 had at least four years of formal training. S o m e of these
practitioners work in highly scientific health areas while others remain in religious
and folk medical practices. Leslie posits that the health system in India encompasses
continua along two axes: one extending from folk medical practice to popular
culture medicine and the other from the learned secular medicine to the learned
religious medicine. Geographically, the practitioners can be located along these
axes. Since the two dominant traditional medicines are sanctioned, health con-
sumers do have access to them. Although these practices are not officially recog-
nized by the government, there is substantial defacto integration, since throughout
Indian society, the health consumers 'use whatever forms of medical knowledge
and practice are available to them' (Leslie, 1977, p. 517).
The pragmatic approach which health consumers take m a y be a reason w h y
the People's Republic of China decided to integrate traditional and Western
medicines. If adequate health care is to be delivered to its vast population, some
means must be found to provide a broad health coverage. By resurrecting traditional
medicine and by training nearly a million 'barefoot doctors', China is attempting to
solve this problem (see W e n and Hays, 1975, on medical education; W e n and
Hays, 1976, onfinancinghealth care; N e w and N e w , 1975 and 1977, on the training
of barefoot doctors). In adopting these strategies, the traditional curers m a y have
 Traditional and modern health care 493

been drawn within the orbit of scientific medicine, which the government defines
as partly traditional and partly Western medicine. At the same time, it is creating
more specialists, such as the 'barefoot doctors', along the 'learned secular medi-
cine and popular culture medicine' ends of Leslie's two axes. Unlike India, China is
attempting to eliminate the folk medical practice and the learned religious medicine
by incorporating health personnel in those sectors into its State medicine. Other
concomitant changes have also occurred. For instance, formal degrees are no longer
awarded. B y this strategy, it hopes to remove barriers that once existed which cre-
ated status differences between health personnel at different levels. In carrying out
these changes, China illustrates, in idealized form, what Novarro has suggested.

Postscript

The argument which is advanced is that while there is growing evidence that health
consumers consult m a n y varieties of healers, the prevailing m o d e of health care
delivery in most countries is still predicated o n the cosmopolitan medical model.
Thus, the providers can easily ignore the consumers w h o d o not subscribe to its
precepts. They are shunted aside as the 'weird ones w h o go to quacks'. S o m e
countries n o w recognize the dangers inherent in this view, in that large segments
of their population can be denied good health care. At present, there is no 'solid'
data to show whether a pluralistic m o d e of health delivery has great advantages,
partly because most governments feel it is useless to collect information of this sort.
O n e can only hope that in the near future the People's Republic of China, which
seems to be committed to integrating traditional and Western medicines, would also
be thefirstto allow researchers to assess its effectiveness. Then w e would all benefit.

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 Some indicators
of medical autonomy in Warsaw 1

Anna Titkow

Introduction

M u c h attention has been paid to the relationship between the world of laymen and
that of medicine. But this relationship has been differently perceived and described,
sometimes as a conflict of interests, sometimes as a case of mutual adaptation, and
sometimes as a situation characterized by subjugation of the layman by medicine.'
This article aims to describe this relationship from the standpoint of the
layman's medical autonomy and the medical professions. Certain aspects of such
autonomy are evident atfirstglance, such as withdrawal from using professional
medical assistance, or postponement of contacts with physicians. Both types of
behaviour are valued negatively, at least by medical professionals, and have motiv-
ated several researchers as well as administrators in charge of health service organ-
izations to seek causes. These investigations have generally identified 'external
factors', of an impersonal nature, and 'internal factors' conceived as various personal
attitudes concerning the utilization of professional medical assistance.
W e shall concentrate here o n still another factor contributing to medical
autonomy: the discrepancy between actual utilization of medical assistance and a
disposition to m a k e use of it.3
This factor has been suggested by and formulated on the basis of empirical
material gathered in our sociological research, which showed nevertheless that
96 per cent of Warsaw's inhabitants sought a doctor's help w h e n they were ill:
64 per cent of them contacted a doctor within thefirstfew days after the appearance
of symptoms.* O n the other hand, 79.7 per cent of the respondents declared that they
met obstacles of one kind or another w h e n they decided to contact a doctor.
Thesefindingstestified to the great success of medicine and the ideals which it

Anna Titkow, one of thefirstsociologists in Poland to have been employed by health institutions, is
now attached to the Institute of Philosophy and Sociology of the Polish Academy of Sciences,
Nowy Swiat 72, Palac Staszika, 00-330 Warsaw. She has published a number of articles, including
a trend report on sociology of health in Poland in Current Sociology, Vol. 23, and is completing a
study on social differentiation in medical behaviour.

Int. Soc. Sei. J., Vol. X X T X , N o . 3, 1977

Some indicators of medical autonomy in Warsaw 407

promotes; almost the entire population under study6 displayed rational behaviour.
But the success w a s not complete, since the majority of the respondents admitted
that when they decided to visit a doctor after the onset of initial symptoms they did
so only after a certain mental struggle.
A s a synthetic indicator of medical autonomy w e have taken the discrepancy
between actual utilization of medical facilities and a disposition to m a k e use of
them. This indicator consists of a number of elementary components, representing
various dispositions to contact a doctor, which constitute different facets of indi-
vidual autonomy. W e shall discuss this indicator here from three points of view:
(a) distribution and interrelationships of the identified features with other features
characterizing respondents; (b) dependence o n the biological component; and
(e) identification of attitude syndromes representing different ways of facing the
necessity of consulting a doctor.
Subjects were given a list of circumstances which potentially m a d e it difficult
for them to visit a doctor and were instructed to single out those which played a
substantial role in their o w n cases. It turned out that the most widespread discour-
agements were: high tolerance for light symptoms, trust in h o m e therapy, general
dislike of visiting a doctor, especially when only minor symptoms were manifest.
A negative assessment of the doctor's work w a s conspicuously m o r e infrequent
than matters like general distrust of doctors, overburdening by h o m e or vocational
duties, etc.
W e expected tofindnotable differences between groups with different levels of
education and believed that they would identify different barriers preventing them
from seeking medical help,* but this was not generally supported by our findings.
T h e population under study displayed high uniformity in their attitudes whenever
the necessity of seeking a doctor's help arose. In certain respects, however, our
initial expectations were confirmed and at least two regularities could be found
which ran counter to the dominant trend towards homogeneity of attitudes: higher
levels of education coincided with more frequent statements on the part of respon-
dents that professional duties and unwillingness to call a doctor if only minor
symptoms were manifest were primary barriers. Lower levels of education coincided
with higher degrees of declared embarrassment about the desirability of seeking
medical help, overburdening with h o m e chores and fear of having a serious disease
discovered as the primary barriers.
Several studies of Polish society have depicted various forms of cultural
difference by reference to the level of education of the respondents' parents or to the
type of settlement inhabited at the time of early socialization (village v. city, strongly
v. weakly urbanized areas).7 O u r study, however, did not bear out a correlation
between factors of this kind and dispositions to consult a doctor.
The cultural background of the respondents affected their disposition to
consult a doctor to a very low degree.
By adding up the number of items picked out by respondents w e changed the
498 Anna Titkow

qualitative character of the inquiry into a quantitative one, where the n u m b e r of

selected barriers represented the degree of 'inhibition in consulting a doctor'. W e
assumed in other words, that the n u m b e r of declared hindrances was itself an
indicator of the intensity with which these barriers were perceived. Consequently,
w e found that there was n o statistically significant correlation between the intensity
with which the barriers to consulting a doctor were perceived and different forms of
socialization, different levels of education, sex or age.
For the W a r s a w population covered by our research it can safely be stated that
medical autonomy is 'egalitarian' by nature, being uniformly distributed over the
different constituent categories.
T h e further analysis of autonomy called for confronting thesefindingswith
biological components. There were three groups of respondents differentiated by
their medical biographies: group one consisted of those w h o had not fallen ill for
two years prior to the inquiry, group two consisted of those w h o had been ill
occasionally over that period and group three consisted of those w h o had suffered
from a chronic disease. Further analysis showed that the medical biography modified
the correction between the level of education and the intensity with which the
obstacles to consulting a doctor were felt. But only amongst those w h o had not been
ill for two years was a significant correlation between the level of education and the
number of hindrances identified observed. Higher levels of education coincided
with stronger declared unwillingness to contact a doctor.
In this part of our analysis w e took into account an indicator of the intensity
of critical attitudes towards the socialized health service. W e surmised that the t w o
indicators of intensity might be interdependent and that unwillingness to consult a
doctor might be the result of perceiving shortcomings in the operation of medical
institutions.
In fact, w e found that, for all levels of education, m o r e complaints about the
functioning of medical institutions coincided with greater objections to consulting a
doctor. However, w h e n w e introduced the medical biography as an intervening
variable w e found that there was a positive correlation between the intensity with
which the barriers to consulting a doctor were perceived and the intensity with
which complaints about the functioning of the socialized health service were voiced
only in that group which had not been ill for two years, and which consequently w a s
deprived of experiences of recent and direct dealings with the health service.
These findings unequivocally testify to the dependence of attitudes on the
organic components presented here as a type of medical biography. Personal
autonomy as manifested by attitudes inevitably intertwined with emotions and
evaluations shows a different pattern, at least to some degree, if actually coping
with a disease was experienced.
While such dependence of the intensity of attitudes concerning contacts with
doctors o n experiences connected with actually being ill should presumably be
ascribed to general h u m a n traits, the population under study displayed certain
Some indicators of medical autonomy in Warsaw 499

specific features which have been generalized in our analysis intofiveattitudinal

syndromes operating in situations w h e n contact with a representative of medicine
became a necessity. These syndromes indicate that there are different but fairly
specific emotional and intellectual structures which dominate behaviour irrespective
of particular experiences connected with having been ill.
W e identifiedfiveattitudinal syndromes (see Fig. 1): (a) preference for non-
medical forms of help together with above average tolerance for disease symptoms;
(b) fear of the consequences of consulting a doctor; (c) overburdening by tasks
connected with vocational, social or h o m e duties; (d) distrust of medicine and
physicians in general; and (e) specific distrust of the physicians employed by the
socialized health service institutions.8
These five syndromes can be divided into two groups differentiated by the

Syndrome I

It does not make sense to

41 per cent_ The symptoms will vanish
consult a doctor w h e n only
m a x 4> before I can see a doctor
minor symptoms are present

A contact with I do not

I can cure a doctor is know
myself followed by where to go
series of tests
and further visits

Syndrome II

A contact with a doctor is It is always possible to have a

_61.5 per cent_
followed by a series of further serious disease discovered on
" m a x (j>
visits and laboratory tests examination

I I
I have been
Treatment is often discouraged by Treatment is often I do not like
more painful than difficult access to more painful than consulting a doctor
the disease. the doctor the disease

F I G . 1. Syndrome's structure. The continuous lines show values of coefficient <p exceeding 40 per
cent of its m a x i m u m value, dotted lines symbolize values of coefficient <p in the range of 28-39 per
cent of its m a x i m u m value.
soo Anna Titkow

Syndrome III

Professional duties make it H o m e duties make it

_48.5 per cent_
impossible for m e to consult impossible for m e to
~max$
a doctor consult a doctor

75 per cent max <>

j 61.1 per cent m a x $

Social or institutional
duties make it impossible
for m e to consult a doctor

Syndrome IV

I have a general distrust of physicians and medicine

I |
43.7 per cent m a x <j> 46.2 per cent m a x <fi 4 0 per cent m a x $ 44.1 per cent m a x $

A visit to a I distrust
doctor is followed Treatment is often physicians
by a series of more painful than I do not like to
see a doctor employed in the
further visits and the disease socialized health
laboratory tests service

I I I

It is always possible to
have a serious disease
discovered on examination

level of anti-institutional and anti-medical bias embedded in their constituent

variables.
Thefirstgroup of attitudes m a y be called 'indirectly anti-institutional lay
medical culture' and is characterized by preference for non-medical forms of
healings, fear of unpleasant consequences following contact with a doctor and
overburdening with life tasks.
Some indicators of medical autonomy in Warsaw 501

Syndrome V

I distrust physicians employed in the socialized health service

I
54.2 per cent m a x <|> 4 0 per cent m a x <|> 51.3 per cent m a x <|>

I
Physicians employed in the I have been discouraged by
Physicians are rude or u n - difficult access to the local
socialized health service
pleasant w h e n they deal physician or the o n e at m y
treat their patients u n -
with their patients place of w o r k
equally

i I
I I

A visit to a doctor is fol-

lowed by further visits and
laboratory tests

The second group of attitudes m a y be called 'directly anti-institutional lay

medical culture', and is characterized by general distrust of medicine and physicians,
and specific distrust of the physicians employed by the socialized health service.
In Syndrome I the preference for non-medical forms of healing and above
average tolerance for disease symptoms are rooted in reluctance to seek medical
assistance for what are considered to be minor causes.
In Syndrome II anxiety and the anticipation of unpleasant 'technical' conse-
quences of consulting a doctor (further visits and laboratory tests) coincide with a
suspicion that an unnecessary consultation m a y lead to having a serious disease
diagnosed. This syndrome is a specific mixture of knowledge and emotions. The
functioning of medicine elicits ambivalent responses. Unsatisfactory functioning of
medical institutions, limited knowledge concerning one's health and the paradox
that some cures are m o r e painful than diseases evoke negative emotional responses
amongst potential patients, that is, almost the entire population.
Syndrome III, connected with 'overburdening by life tasks', is the most
isolated from the others. It characterizes a group of persons for w h o m abandoning
their tasks and assuming the patient role is a difficult problem.
All these three syndromes lack direct connections with medical institutions
or their representatives. Syndrome IV, however, is founded on the principal corre-
lations of the variable 'I generally distrust medicine and physicians' and the other
 502 Anna Titkow

variables. Lack of trust in medicine and physicians coincides with other, equally
general dispositions, such as 'I d o not like to see a doctor', etc. Since the socialized
health service is the most widespread form of medical assistance in W a r s a w , it is
only natural that this variable correlates highly with 'I generally distrust physicians'
or 'I distrust physicians employed in the socialized health service'.
In Syndrome V the following general picture emerges from these interrelation-
ships. T h e general distrust of physicians is to a certain degree reinforced by the
distrust of those within the socialized health service. This attitude is connected with
recognition of a certain distance separating patients and the representatives of
medical institutions, which is of an objective nature if it results from the difficulties
which patients meet if they desire to see their local or works doctor. A subjective
distance separates patients from physicians whenever the former say that the latter
treat them rudely or unkindly, or w h e n they say that physicians employed by the
socialized health service d o not treat their patients equally.
W e m a y conclude that indicators of lay medical autonomy m a y be arranged
to form a scale which represents the degree of complexity of the indicators discussed,
specifically: susceptibility to diseases requiring contact with medicine and its
representatives; the syndromes of such susceptibilities; and discrepancies between
the dispositions to contact medical assistance and actual contact.
T h e third indicator seems to be particularly significant. The concurrence of
rational behaviour over illness with evidence that the required behaviour is perceived
as a 'necessary evil' raises a number of questions such as: to what extent is this
coincidence typical of Poland or is it congruent with different modern represen-
tations of the relationships between the laymen and medicine? These questions,
however, go beyond the scope of this presentation.

Notes

1
The research was conducted in 1972 on a represen-
tative sample of 1,165 adult persons in W a r -
saw, as part of the author's P h . D . thesis.
This article is based on a note presented to
the International Conference of Medical Soci-
ology in Paris, July 1976.
2
See for example Samuel W . Bloom and Robert N .
Wilson, 'Patient-Practitioner Relationships',
in H o w a r d E . Freeman, Sol Levine and
Leo G . Reeder (eds.), Handbook of Medical
Sociology, Englewood Cliffs, N . J . , Prentice
Hall Inc., 1972.
3
This approach benefits from the conception of
Eliot Freidson w h o holds that two systems
compete for the control over medical be-
haviour, the lay and the professional ones.
See Eliot Freidson, ' Client Control and Medi-
cal Practice', in E . Gartly Jaco (ed.),
Patients, Physicians and Illness. A Source
Book in Behavioral Science and Health, Free
Press, 1972.
* These findings m a y be compared with those of
K . L . White et al, w h o found that out of
three average persons w h o admit being ill
when interviewed at h o m e only one goes to
see a doctor: 'The Ecology of Medical Care',
New Engl. Jour. Med., 1961.
5
O f the interviewed population 99 per cent had the
right to apply to the socialized health service
for free assistance.
e
Level of education is considered here to be a socio-
cultural fact underlying other variables of
social status, attitudes, dispositions, systems
of values, etc.
Some indicators of medical autonomy in Warsaw
Notes {continued)
7
See for example A . Pawelczynska, Dynamika
przemian kulturowych na wsi. Metoda badania
glownych tendencji [The dynamics of cultural
changes in the village; A method of studying
principal trends], Warsaw, 1966.
8
Different coefficients have been used in this analy-
sis, including the table of significant values
for chi squared. Since the values to be
checked against this table came from two by
503
two contingency tables the dependence of any
two variables could easily be measured by
means of the phi coefficient. The typology of
causes responsible for delaying a contact
with a doctor has been based on the strongest
and the most strongly correlated variables,
i.e. those which reached the highest percent-
age of the m a x i m u m phi value.
 The medical profession

Doctors of thefirstline
in Czechoslovakia

V . Bflek and J. Balogh

T h e most sensitive site of contact of the public with any system of health services
is the entry into this systemthefirstline physician, or health community doctor
(general practitioner). In Czechoslovakia, where particular emphasis is laid on the
provision of health services and their standard, this contact is not ensured by an
individual but by a small team of doctors and nurses, incorporated in the organ-
izational structure of health services, the principles of which m a y be summarized
very briefly as follows:
All health care including drugs and medicaments prescribed by doctors is
free, services being widely available. They are controlled and planned by the State
via the Ministry of Health and regional and district national committees. In every
district there is an institute of national health which comprises all facilities for
ambulatory care (health centres and polyclinics) and in-patient care (hospitals and
sanatoria), a hygiene and epidemiological station, pharmacies and a school for
paramedical workers. The entire district is divided into territorial health c o m m u n i -
ties (with populations of 3,500-4,000). The adult population, as regards therapeutic
and preventive care, is looked after by a doctor on a full-time basis, children
under 15 by a paediatrician on a half-time basis (who covers two health c o m m u n i -
ties), a gynaecologist working forfivehealth communities and a full-time dental
surgeon. Each of these doctors is assisted by an appropriately trained nurse. Care
of workers of larger factories and enterprises is ensured by factory medical officers
w h o , in collaboration with nurses, look after 1,000-2,000 employees, depending on
the type of enterprise. In large enterprises specialists are also employed in the
factory polyclinics. Health community services in rural areas are concentrated in

Vilibald Bilek is Professor of Social Medicine in Prague and Director of the Institute of
Social Medicine and the Organization of Health Services (USLOZ), 54 Sokolska, Prague 2
(Czechoslovakia). He is also the editor of the monthly Czechoslovak Health Services. His main
current interests lie in the investigation of undergraduate medical training world-wide.
Jindrich Balogh is Associate Professor and senior researcher at USLOZ. He started his
career as a general practitioner in a rural area. His main concerns lie with problems of work inca-
pacity and epidemiological surveys of general morbidity, on which he has published in Czech and
French (published in Bucharest).

Int. Soc. Sei. J., Vol. X X T X , N o . 3, 1977

506 V. Bilek and J. Balogh

health centres, in towns in polyclinics where specialist services are also provided.
Polyclinics, like hospitals, are subdivided by the catchment area and function
according to three types classified by size a n d facilities. T h e network of health
community, factory doctors and specialists with in-patient facilities is relatively
evenly distributed.
T h efirstcontact and basic medical servicescurative, preventive and in the
field of hygiene, epidemiology and health education in health communitiesis thus
ensured by a team of doctorsthe general practitioner, paediatrician, gynaecologist
and dental surgeon, which to a considerable extent is a feature specific to
Czechoslovakia. The domicile of the patient is the decisive factor which determines
which doctor has him on his list: it is equally possible to select another doctor but
very few people take advantage thereof. Since it looks after a certain groupin
particular in rural areasthe team to a considerable extent acts in the capacity of
personal or family doctors because it k n o w s the living and working conditions of
the population entrusted to it closely. The central position in this team is held by the
health community doctor.
H e is trained at post-graduate level and before he is appointed must have at
least three years' practice in a hospital with a polyclinic, pass an examination in
internal medicine or surgery, in exceptional cases in another specialty and a sup-
plementary examination for the post of health community doctor. The paediatrician,
gynaecologist and dental surgeon m a y w o r k in thefieldonly after they have passed
the required examinations. T h e team offirst-linedoctors is thus well equipped for
field work and can ensure high-standard care of the population.
Health community doctors and paediatricians are, in our opinion, typical
representatives of the socialist concept offirst-linedoctors with all their attributes.
In their position and working duties the principles of socialist health care are not
only reflected most markedly but equally mirror those features which, in countries
with a different social system, usually characterize the role of thefirst-linedoctor
with his wide spectrum of diagnostic and therapeutic activities and a specially close
relationship with the public.
The specific feature of the work of the health community doctor, as compared
to that of specialists, is in particular that it is m u c h less medically differentiated and
that activities are confined to a relatively stable population group under his care,
F r o m this ensue wider responsibilities and thus also essential knowledge which m a y
be summarized under seven categories:
Diagnosis,firstaid and if necessary referral to a specialist or hospital.
Treatment of c o m m o n and complicated diseases in the surgery or in the patient's
h o m e (domiciliary service).
Informing patients on a correct living and therapeutic rgime, health education of
the public by lectures, etc.; advising national committees, factories, agri-
cultural co-operatives, schools, R e d Cross, etc.
Comforting patients, gaining their confidence, becoming familiar with their
 Doctors of thefirstline in Czechoslovakia 507

personal, social and working environment and assisting them with resolving
non-medical problems which have a bearing on their health.
Active care of the entrusted population by preventive examinations and dispensary
care, consultations with specialists; keeping the appropriate records of the
health status of examined and treated subjects.
Supervision of personal, c o m m u n a l and work hygiene, ensuring the necessary
epidemiological measures and mobilization of the public to participate in
health-promoting activities.
Assessment of health status with regard to different occupations and for the needs of
sanatoria, convalescent homes and spa care, provision of certificates for
purposes of social welfare, keeping records, preparing reports, etc.
The health community doctor thus participates more than the majority of other
doctors in activities in the sphere of social control and in organization. D u e to his
frequent contact with a closed circle of patients and because he is near to their life
and environment, he also participates m o r e than the majority of other doctors in
emotional support. H e is most readily available to the population. People have
direct access to him and it is he w h o refers them, in a differentiated manner, to the
complexities of the health system. H e encounters m u c h more often initial and first
forms of diseases, and himself deals with the majority of c o m m o n diseases. Direct
patient access makes it m o r e difficult for him to organize his work and the health
community doctor therefore suffers from shortage of time m o r e than others and is
less technically equipped. Contrary to the majority of other doctors, he resolves, on
a m u c h wider basis, patient problems which are not only somatic but also social and
emotional. His working procedures, in view of the large variety of diseases he treats
himself, and because of his simple technical equipment, are most easily evaluated
and controlled by laymen (also because the public can confront the conclusions of
health community doctors with those of specialists). Decisions of health community
doctors m o r e frequently than those of others concern the social functions of patients
and their families. H e certifies various deviations in the patient's life, and, contrary
to the majority of other doctors, is not concerned only with spells of diseases but
actively follows up the life of the entrusted population groups in health as in illness
and intervenes in their living conditions.
Since the health community doctor is the most exposed link in the system of
health services it is logical for the greatest interest to be focused on him and for him
to become the centre of the reported research.

Methods, organization and technique

Investigations had a theoretical and empirical character with a well-defined practical

objectiveto provide an answer to urgent and important problems relating to the
improvement of the health services. Theoretical findings of previous research
508 V. Bilek and J. Balogh

Gladkij, 1967; Kutej, 1969; M a n e k , 1970; Winter etal, 1970) and experience from
practice at various levels of the uniform Czechoslovak health services were used
as bases.
The main elements of the investigation were the following: (a) aspects of
health policy, emphasizing the role of ambulatory services in the provision of health
care to the population; (b) theoretical aspects of social medicine taking into account
that the health community system is one of the socially most exposed components
of Czechoslovak health services; (c) long-term and current problems of practical
health services which reflect a number of changes, in particular the emerging
structure and intensity of health needs in conjunction with social, cultural, d e m o -
graphic, scientific and technical trends of social development; (d) the internal logic
of the development of the research base, in particular scientific training, conditions
pertaining to staff, organization and material supplies which have led from
'mapping' of individual aspects of the health system to the d e m a n d and possibility
of making a m o r e comprehensive, systematically conceived analysis of the entire
subsystem of health community services.
The methodological basis of the research was therefore a confrontation of the
functions and structure of health services as a subsystem of health services as a
whole, with the actual trend and results in implementation and the attitude of the
public and of health community workers. Functions and structures were formulated
as codified in norms and as practised.
The investigation w a s focused in particular on those aspects of health
community services where this confrontation is most marked, particularly pro-
fessional tasks and activities of doctors and nurses of thefirstline, identification and
satisfaction with the profession, professional value orientation, prestige of the
profession, as compared with other types of doctors, psychic traits of the person-
alities of health community doctors, relations between health workers, patient-
health community doctor and nurse-relations, attitudes and expectations of the
public, effect of working conditions and training for work in thefirstline of health
services, co-operative activities in the health community with polyclinic and hospital
facilities and selected problems of management of the health community services.
For present purposes only certain aspects have been selected.
The investigation w a s further conceived as an analysis of object-subject
relations because, in health community services more than elsewhere, there are
frequent points of contact between persons and the surrounding social reality.
Marxist sociology of medicine in socialist countries (Agajev, 1970; Parin, 1971) and
relevant pioneer work in other countries with advanced health services of the first
line (Cartwright, 1967; Mayntz, 1970) were used as bases.
The investigation w a s undertaken in 1970-72 as a complementary and
confrontational combination of twofieldsurveysan opinion survey of a represen-
tative group of 1,428 citizens and of 2,713 health workers in eighteen districts.
In the preparatory stage of the investigation legal norms were analysed and an
 Doctors of thefirstline in Czechoslovakia 509

analysis was m a d e of statistical data of the investigated districts. Thefielddata were

collected by means of a standardized questionnaire interviews and psychological
tests.
T h e analysis of findings was processed into thirteen reports on diffrent
problemsa total of some 900 pages and numerous tables and graphs. A synthesis
of the results is contained in thefinalreport Health Community System of Health
Care ( S L O Z , 1973). In this article w e shall outline suchfindingsas m a y also be of
interest to foreign specialists.

Views, attitudes and expectations of the public

Opinion surveys conducted as thefirststage of thefieldsurvey aimed to assess

whether the public is aware of its real needs as regards health protection, its attitudes
and what it expects from health services, in particular from health community
services (Skrbkov et al., 1971).
It was confirmed that citizens valued most highly a m o n g ten submitted,
generally important features their o w n health (importance index 5.866), third place
after 'harmonious family' being held by 'health of family members' (3.913). Both
values pertaining to health scored higher than such attractive values as 'sufficient
money', 'interesting work', 'good friends', 'good social position' and others. This
value orientation is favourable to the acceptance of health protection and, n o doubt,
had a bearing on willingness to answer further questions. Analysis of findings, h o w -
ever, shows that the high value attached to health is not automatically associated
with greater efforts for its protection. Those with the highest appreciation of health
d o not manifest significantly greater initiative to use health services.
T h e decisive factor in relation to health services, in particular health
community services, is experience in the provision of medical care. It was revealed
that the general satisfaction of citizens with health community services creates a
very favourable image of the latter. O f the citizens 61.2 per cent are satisfied with the
services of the health community doctor, 26.1 per cent express certain reser-
vations, only 6 per cent are dissatisfied, the remainder having n o opinion. While
the responses do not vary significantly according to sex, education, social group or
size of domicile, citizens above 40 are significantly m o r e satisfied with health
community services; satisfaction is also closely associated with the number of visits
to the doctor's surgery. It is interesting to note the expectations from health
community doctors: above all the wide interest not only in actual illnesses but in
general health and social problems which m a y be associated with disease (57.4 per
cent of the respondents). In this connection respondents emphasize the role of the
doctor as an emotional supporter and adviser in their personal life; most of them feel
that it is useful to inform the doctor also of their non-medical problems.
For comparison, w e used the same question as a French survey in 1959
510 V. Bilek and J. Balogh

TABLE 1
Czechoslovakia (1971) France(1959)

% %
A good thing 65.9 42.0
N o t a good thing 10.4 31.0
Depends on circumstances 22.0
N o answer 1.7 27.0

{Revue Franaise de VOpinion Publique, 1960): D o you think it a good thing to

discuss with your community doctor your private troubles? For the replies, see
Table 1.
While one different category makes the answers not completely comparable,
w e m a y conclude that in both countries there is a strong trend to view the doctor as
an emotional supporter.
At the same time the public is aware of the variety and broad spectrum of
activities of the health community doctor and, o n the whole, agrees with it. It
particularly appreciates his therapeutic functions, rapid diagnosis of illnesses,
assessment of w o r k incapacity, his role as confidant and adviser, his information
and guidance as regards a healthy way of living. Elimination of shortcomings in
hygiene and preventive examinations are considered somewhat less important.
In the minds of the public the desirable personality traits of the health
community doctor are the following, in close order of preference: sensitivity, high
professional standards, working with dedication, self-sacrifice, obligingness and
patience, while the following factors are considered less important: strictness, a
firm and coherent stance, age. Least interest is displayed in the private life of the
health community doctor.
Although the esteem and authority (Provaznik, 1972) ascribed to the health
community doctor suggests a relatively favourable position in the health community
services, there is a general trend to accord higher prestige to specialized and more
elevated jobs in the professional hierarchy, and in the scale of prestige offivetypes
of doctors, the local health community doctor was only given fourth place (hospital
consultant first place 3.932; local health community doctor fourth place,
index 3.453). Thisfindingis differentiated and depends on the size of the community:
the prestige of the health community doctor declines with the size of the community,
being lowest in cities of more than 100,000.
A n important factor in the prestige of the local health community doctor is
the extent to which patients appreciate his attitude in two respects: information on
the type of treatment, on taking medicaments and behaviour during illness, and
kindness and patience in relation to the sick. T h e more they appreciate these, the
higher the prestige of the health community doctor. The frequency of visits is also
important. Patients w h o see their doctor more frequently rate his prestige signifi-
cantly higher.
 Doctors of thefirstline in Czechoslovakia 511

Views and attitudes of health community doctors

For comparison with the views and expectations of the public, investigations were
conducted in health communities, a m o n g doctors in polyclinics and senior workers
w h o control the community services, o n objective and subjective conditions for
ensuring health care, assessed with emphasis on the implementation of this function,
on interpersonal relations, the personality and other qualities of doctors.

Role of thefirst-linedoctor
W e used as a basis the indicated specificity of the role and activities of the health
community doctor and evaluated twenty-one types of activity, comprising seven
partial professional roles. T h e doctors evaluated the importance of different
activities and the popularity of their implementation (Gladkij, 1972).
Doctors of thefirstline considered as most important their role as the first
person to establish a diagnosis (index 151), as therapeutist (106), as emotional
supporter and adviser (73), as organizer of therapeutic and preventive care (65)
and as health educator and adviser (50). A m u c h lower score was obtained by the
following partial roles: health administration official (25) and official and organizer
of community health care (20).
A m o n g different types of activities of which the partial roles are m a d e up,
local health community doctors constructed the following hierarchy of importance:
Ranking
Activity of importance
1. First contact with patient, establishment offirstdiagnosis 97
2. First aid 96
3. Informing the patient on correct living and therapeutic
regime 86
4. Assessment of work incapacity 74
Domiciliary services in families 73
5-6.
\ Keeping records o n examined and treated subjects 73
7. Consultations with specialists, provision of care rec-
o m m e n d e d and integration therewith 71
8. Role as the patient's confidant, comforting patient 70
9. Treatment of c o m m o n (simple) disease 68
10. Selection of patients referred to specialized departments
of polyclinics and hospitals 67
11. Epidemiological activities 61
12. Active care of entrusted population (preventive examin-
ations, dispensary care) 48
13. Becoming familiar with personal, social and working
environment of patients 44
14. Treatment of complicated cases 42
512 V. Blek and J. Balogh

A s for the hierarchy of partial roles, the m o r e detailed analysis of types of activities
revealed interesting relationships. U r b a n health community doctors, m o r e than
rural ones prefer assessment of work capacity and consultations and collaboration
with specialists of hospitals and polyclinics. Older respondents with longer practice
ascribe m o r e importance to tasks in the sphere of prevention or public health
protection, while junior ones prefer the partial roles of the therapeutist and primary
diagnostician. The position as regards different types of activity is similar: senior
doctors m o r e than junior ones appreciate hygienic, epidemiological and health
educational activities, informing the patient about his disease, mobilizing the
public for health promotion, collaboration with public authorities and documen-
tation and records.
T h e extent of the functions of the health community doctor, at the interface
between the health services and the public, with strong social exposure, is to some
certain extent controversial in as far as demands m a d e o n them are concerned, as
manifested particularly in two respects: greater feelings of overloading and the
impression that their professional skills are not fully used. Such feelings were
stronger than a m o n g doctors in polyclinics and hospitals. According to health
community doctors they were best prepared for traditional medical activities but
less for those typical of the preventive trend and activities associated with their
function as afilterfor other specialized services and the synthesis of specialized
findings within the developed system of division of labour. They felt they were least
prepared for their public functions in health protection and for the psychological
approach to patients (Polcek, 1972). T h e latest revision of post-graduate training
for work in health communities published at the end of 1972 to a considerable
extent took these views offieldworkers into account.

Influence of the working climate

of health community doctors
T h e working exposure of health community doctors is at least roughly apparent
from the fact that in 1970 they participated in 40.29 per cent of all ambulatory
examinations and treatment, though the number of doctor's posts in the entire
territorial ambulatory services is only 25.27 per cent.
Doctors must in some cases take decisions under pressure of time which
makes it difficult to obtain information and continuously follow up the patient.
Doctors are very disturbed about this, as the responses show. Decisions taken under
pressure of time and with inadequate information occasionally alarm 64.5 per cent
of health community doctors, cause constant tension to 21.2 per cent while only
13.9 per cent are not upset by them. This provides indirect evidence of the great
sense of responsibility of doctors but at the same time has a bearing o n satisfaction
with their functions. It was demonstrated that this type of tension significantly
reduced satisfaction with the profession; the dissatisfied include 30.8 per cent of
 Doctors of thefirstline in Czechoslovakia 513

T A B L E 2. Rate of conflicts of territorial health community doctors with partner groups (12= 515)

Rate of conflicts as percentage

Partner group Fairly Occa-
Rarely N o answer Sum
frequent sional

With patients 1.75 17.67 79.81 0.78 100

Patients with doctors (=1428) 3.40 16.30 73.50 6.80 100
With health community nurses 2.52 8.16 77.67 11.65 100
With health community
paediatricians 1.55 3.11 82.52 12.82 100
Paediatricians with doctors (=228) 1.75 10.09 76.32 11.84 100
With specialists in the ambulance
services 2.52 7.57 82.73 7.18 100
Specialists with doctors (=309) 1.30 16.50 79.94 2.26 100

those w h o experience constant tension in these instances and only 7.3 per cent w h o
are not upset by them.
The wide and intensive interaction of doctors of thefirstline with the public
and various categories of health workers is another important characteristic of their
social condition, being associated with tensions for which w e used the rate and
degree of conflicts as indicator. Although the health community doctor cannot
avoid conflicts, Table 2 indicates that their incidence is not high and depends on
kinds of partners.
W e wish to add that in all instances conflicts are involved which can be
overcome and are c o m m o n in working contacts; the overall incidence of conflicts is
low (Stolnov, 1972).
Other problems generally confronting the health community doctor, including
transport, salaries, professional and methodical guidance, co-ordinating tasks
in relation to colleagues, co-operation with social authorities, the relationship
between universal and specialized care of patients, co-operation of health c o m -
munity and specialized services, and the effects of external conditions, were also
investigated.

Identification of health community doctors

with their profession and personality traits
The strenuous and complex working conditions in the health community are
balanced out by factors which motivate the health community doctor to cope with
tensions and focus on the positive social and personal aspects of his work.
Health community doctors confirmed this trend in the degree of satisfaction
with their o w n profession (Gladkij, 1972)-17.5 per cent very satisfied, 61.2 per cent
satisfied, 16.3 per cent selected a neutral answer, and only 5.8 per cent dissatisfied.
514 V. Bilek and J. Balogh

100% F I G . 1. Degree of satisfaction with profession in

relation to period of service of health community
90 doctor (rt=515,p=0.001, C n o r m = 0 . 3 1 8 ) .
87.9

s
80 /
s 75.4
74.5'
V '71.7
70
s
65.8
60

50

5 10 15 16!

Years

N o significant difference emerged as between doctors in rural or urban communities

nor as between m e n and w o m e n . Significant relationships were shown by correlation
between the degree of satisfaction and the length of career, as apparent from Figure 1.
W h a t also emerged was a significant relationship between higher satisfaction
with the profession offirstline doctor and the scale of values and psychic features of
personality. Those w h o are more altruistically humanitarian, than on clinically
oriented are more satisfied, that is, those w h o do not have great professional
ambitions, are inclined towards social activities, are psychically more resistant to
insecurity and risk and have a more stable nervous system. This also fits in with the
finding that those whose main motive for studying medicine was their wish to help
the suffering rather than professional and other interests, are more satisfied. Signifi-
cantly m o r e satisfied also are those w h o enjoy public activities, the interesting
character of their work, and w h o have the impression that their specialized
knowledge is used. Moreover, the degree of satisfaction depends significantly o n
interest in the chance to specialize, on degree of overburdening, the feeling of a just
evaluation of work by superiors, on the frequency of conflicts, and o n external
working conditions.
A pertinent picture of identification with the profession is obtained from the
value orientation of doctors of thefirstline (Purkrbek, 1972), ranked as follows
(n=963):
Number
Value of points
1. Be a doctor popular with people because of his self-sacrifice and
understanding 2,663
2. Have a clear conscience 2,256
 Doctors of thefirstline in Czechoslovakia 515

3. Be considered capable 1,546

4. Have the opportunity to consult on professional problems 1,232
5. Be appreciated by superiors 1,152
6. Have an opportunity to engage in a medical specialty 978
7. Have an opportunity to take independent decisions 866

Special attention was also paid in the survey to the standard of legal knowledge of
health community doctors since their legal duties are relatively extensive (Stpan,
1972). It was found that such knowledge is relatively good, in some cases surpris-
ingly good and m u c h better than that of other specialists; it improves with length
of service. It is worth noting that doctors with better legal knowledge have a signifi-
cantly lower rate of conflicts with collaborators, patients and superiors. They also
identify themselves more with basic conceptual solutions of the health services, have
a more realistic attitude to the mastering of their duties and are somewhat less fre-
quently dissatisfied with their profession. A certain relationship was also manifested
with personal characteristics. Doctors with a high degree of bold spontaneity and
medium values of extraversion have a higher standard of legal knowledge.
A n assessment of the psychological characteristics of doctors of thefirstline
(Balear, 1972) was included as a supplementary element in the survey. The object of
the application of psychological tests (Parmia factor from Cattel's test 16 P F ,
extraversion, neurosis and L score by means of Eyseneck's personality question-
naire EPI) was to obtain a notion of the existing and dominant psychic traits of health
community doctors and to check the validity of assembled information. A m o n g the
most importantfindingsw e m a y mention that in the Parmia factor which has a scale
in the direction 'fearful shynessbold, spontaneous behaviour' higher values were
recorded by territorial health community doctors as compared with factory medical
officers and paediatricians. This indicates that for the work of local health community
doctors more active, spontaneous individuals, less sensitive to risks are better
suited.
At more advanced age the Parmia values are also higher, while extraversion is
lower. It is apparent that as a result of professional development in association with
maturation, the ability to take risks controlled by careful reflection increases.
A remarkable relationship was found between types of doctors according to
their value orientation and the degree of neurosis. Doctors with predominantly
humanitarian leanings, contrary to those oriented mainly to medical issues and
organizational problems, displayed a significantly lower rate of neurosis. This
shows that a predominantly humanitarian orientation leads to fewer neuroticizing
situations and also makes it possible to attain better mental balance and self-
reliance. Markedly higher values of neurosis are to be found amongst the youngest
doctors of thefirstline, which suggests that they respond to the demands of their
work with greater difficulty and to a certain extent also points to the fact that
doctors with a greater nervous instability leave their job after a time.
516 V. Bilek and J. Balogh

Patient-doctor relationship
T h e survey also helped to elucidate relations between citizens and the health
community service.
A m o n g the public confidence in the health community doctor prevails, plus
a generally positive evaluation of his professional and h u m a n qualities. T h e patient
expectation that the doctor will take an interest not only in his illness but also in
family and social relations, corresponds to the view of the majority of doctors as
regards their role and the scope of tasks. T h e basic problem is that of time.
Complaints by patients and doctors usually revolve about the relative shortage of
time for the individual patient.
Research also reveals the high sense of responsibility of doctors for the health
of the population entrusted to them. Given such a value orientation, in situations
of stress or conflict and other investigated aspects concerning the doctor, the
patients' interest decisively governed all others. A more detailed analysis of the
material indicates that this is not due to the adaptation of doctors' responses to
generally accepted social n o r m s but reflects their true belief.
T h e Czechoslovak system of health services leading to contact between
citizens and doctors also in the absence of disease (during preventive examin-
ations, etc.) creates a favourable climate for the patient: attendance at the surgery
thus becomes a natural continuation of previous contacts. T h e psychologically
difficult contact with the doctor 'only w h e n one feels miserable' is thus to a certain
extent eliminated.
But even under these conditions it is not easy to play the role of patient. It was
found that only one-fifth of the patients visit the doctor w h e n necessary willingly and
immediately, while 27.7 per cent hesitate and 43.3 per cent consult only w h e n they
have serious complaints. There is a marked relationship with subjective health
status: the admitted readiness to see a doctor is m u c h higher a m o n g those with a
well-defined condition than those w h o dwell in uncertainty on the nature of their
disorder. This is further confirmed by m o r e than a quarter of the respondents w h o
reported that, at the time interviewed, they suffered from certain complaints but did
not see a doctor. These findings refute the idea that generally available free care
automatically leads to its full or even excessive use.
In the role of patient emotional inhibitions are strongest, particularly uncer-
tainty about future outlook, fear of pain, of becoming an outsider, and of the
strange surroundings of the health institution. F r o m this point of view, an important
test of the patient-doctor relationship is the extent to which the health community
doctor dispels the patients' fears: half the patients report a positive effect on their
fears of a visit to the surgery, but for one-fifth it apparently had n o effect.
Here w e face the problem of communication between patient and doctor,
which not only serves to exchange information but is equally an important diag-
nostic and therapeutic tool. If the patient has confidence in the health community
 Doctors of thefirstline in Czechoslovakia 517

doctor and anticipates interest in his condition, it is understandable for the majority
to feel it also to be a good thing to discuss their personal problems with the doctor.
Such an attitude matches the positive view of doctors in their roles as advisers and
emotional supporters.
A special problem of communication between patient and doctor is the
extent and manner of information in critical situations. Views on this problem have
been assessed repeatedly in different locations and on different occasions in the
world at large, and they vary considerably. Thus, for example, in the French survey
of 1960 already mentioned 73 per cent of the subjects asked to be told the truth in
such situations, however cruel it might be, while 22 per cent wanted the truth to be
kept from them. O n the other hand, in the Federal Republic of Germany (according
to Spann) 56 per cent objected to knowing the truth and only 39 per cent asked for
truthful information. In Czechoslovakia traditional views are held in this respect: in
critical situations only 12.5 per cent of respondents consider it correct to tell patients
the truth, while 50 per cent recommend telling part of the truth and 30 per cent
justify pious fraud. This corresponds roughly to views held by doctors: over
nine doctors out often refuse to provide the patient with distressing truth.

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gards Identification of the Health Community Health Community Services], Praha, S L O Z .
Doctor], J?raha, S L O Z . S T E P N , J. 1972. rove a vyznam prvnlch znalosti
K U T J , B . 1969. Ceskoslovensk zdravotnictvi,Wo\. 17, obvodnich lkaf [Standard and Importance
N o . 10, p. 440. of Legal Knowledge of Health Community
M A N E K , A . 1970. Demografie, Vol. 12, N o . 2, p. 124. Doctors], Praha, S L O Z .
M A Y N T Z , R . 1970. The Nature and Genesisofthe Per- S L O Z . 1973. Obvodnisystem pce o zdravsouhrnn
sonality, some Results of a Study on theDoctor- zvern zprva k vyzkumnmu ukolu [Health
Patient. Relationship. Social Research, N o . 37. Community System of Health CareSum-
P A R I N , V . V . ; K O Z Y R E V A , E . 1971. Zdravoochra- marizing Final Report], Praha, SLOZ.
nnije Rossijskoj Federacii^oX. 1 4 , N o . 7 , p . 3 . WINTER, K . ; H T T N E R , H . ; D A H M , I.; MIEHLKE, G .
P O L C E K , A . 1972. Kproblematike pripravy a kvalifi- 1970. Zeitschrift fr rztliche Fortbildung,
kcie obvodnych lekrov [On the Problem of Vol. 64, N o . 16. p. 838.
 General practitioners in Switzerland

Andrs November

The rapid increase in medical expenditure, which has risen on an average from
3 to 7 per cent of the gross national product ( G N P ) in most European countries in
the space offifteenyears, has led public health authorities and the medical pro-
fession to re-examine the present position of medical practitioners within the health
services. A sociological survey was carried out by an interdisciplinary research team
in Geneva with a view to gaining insight into the problems of the medical community,
with special reference to their professional aspects.1
A sociological approach to a study on medical practitioners is justifiable o n
the grounds that their function is changing in response to the transformation of the
social environment and is also affected by n e w economic and religious trends.2
General practitioners are constantly required to deal with questions which do not lie
entirely within the province of medical science, in the narrow sense of the term, and
they find themselves involved in the professional, emotional and family problems
of their patients. T o w n and country doctors alike are confronted m o r e and more
frequently with cases of sick people and illnesses (more often than not manifestations
of psychological rather than physiological disorders) which they had not been
taught to tackle during their years of theoretical and practical training, for the world
discovered by the general practitioner as he gains experience is fundamentally
different from the one he learned about at the medical faculty. General practice
consequently tends to be marginalized in relation to the medicine practised and
taught in teaching hospitals. W e are becoming aware of a latent cleavage between
hospital medicine, which has access to substantial scientific resources, and the
medicine of the doctor's surgery which is less cohesive, more isolated and often
inadequately equipped.
The research team examined a sample of Swiss doctors3 to obtain the infor-
mation which wouldfilla gap in the literature available on the subject, particularly as
regards a sociological approach to the problems encountered by doctors in the

Andrs November is associate professor at the Institut d'tudes du Dveloppement, 24 Rue

Rothschild, 1202 Geneva. He specializes in micro-economic and micro-sociological studies and is the
author of a book on trade unionism in developing countries.

Int. Soc. Sei. J., Vol. X X I X , N o . 3, 1977

 General practitioners in Switzerland 519

exercise of their profession. T h e aim of the study was to throw m o r e light on practical
medical work. 4
The survey was conducted in two stages. T h efirstwas a qualitative phase,
during which the team reviewed the various possible attitudes of a medical prac-
titioner with regard to the main areas of his activity (diagnosis, therapy and
prescription). In the second phase, the attitudes which had been ascertained and
listed were subjected to an analysis of associated data.
A s regards methodology, the survey was based on recordings of depth inter-
views with the individuals composing a representative sample of doctors practising
in Switzerland. A content analysis of the interviews was m a d e , and the expressions
listed were then processed by computer (factor analysis). This method precludes any
foregone conclusions as to what a doctor's w o r k really involves in practice, for the
criteria established are derived only from the interviews with the doctors. T h e
approach adopted is accordingly based on the weak axiomatic system, which lays
emphasis on discovering the variables that are typical of medical work, rather than
seeking to confirm pre-established hypotheses. The research team thus chose an
appropriate methodology for arriving at a description of the doctors' experience in
their o w n terms. In the subsequent stages of the survey, w h e n the information was
being tabulated and analysed, qualitative and quantitative methods of pursuing an
exhaustive investigation were used alternatively.

Qualitative study of what is involved in a consultation

In informal interviews, doctors were asked to talk about their work and describe
their attitude towards their patients, particularly in the three main stages of the
consultation: reception (making contact), diagnosis and therapy.

Reception of the patient

The doctor's general manner is one of the predominant features of a consultation.

Approaching a patient is a complex, multi-dimensional process which the doctors
described in various ways, using a very wide range of expressions. Four factors
emerge, however, which, taken together, give a general picture of a doctor's attitude
and 'manner' w h e n he receives a patient.
His medical competence, described by the use of terms such as 'scientific', 'well-
trained', 'competent', 'specialized', 'technician', 'experienced', 'a good clinical
sense'.
His personality: 'paternalistic', 'condescending', 'forceful', 'impatient', 'timid',
'pessimistic', 'irresolute', 'uncommunicative', 'distant', 'confident', 'reassur-
ing', 'intuitive', 'meticulous', 'familiar', 'idealistic'.
520 Arlars November

His relationship with his patients: 'tries to establish contact', 'wants to help', 'wants
to give relief, 'spends time with his patients', 'invests a great deal in the doctor-
patient relationship', 'inspires confidence', 'enters into a close relationship
with his patients', 'assumes responsibility for the patient'.
Lastly, his capacity for communication with his patients: 'listens to them', 'talks to
them', 'communicative', 'persuasive', 'takes trouble to explain'.
The initial contact with the patient, in all its complexity, sets the general tone of the
consultation. It is also a decisive factor in the doctor's attitude towards diagnosis
and therapy.

Diagnosis

Attitudes concerning diagnosis tend more than those concerning the initial contact
with the patient to be polarized into two opposing schools of thought, which lay the
emphasis either: (a) on the need to detect and define the illness with the appropriate
scientific means, or (b) on the need to find out more about the patient's personality
even if this means making a less precise diagnosis.
T h e following phrases illustrate thefirstof these schools of thought: 'it is alia
question of natural science', 'we arrive at our diagnosis on the basis of what w e have
been taught', 'diagnosis is a standardized process', 'it is laid d o w n by medical
textbooks', 'diagnosis is objective', 'with good equipment, you can go a long w a y in
making a diagnosis'.
T h e opposite school of thought is reflected in the following quotations:
'diagnosis does not give a clear picture of the individuality of the patient', 'diagnosis
must be broad', 'diagnosis is of secondary importance, the essential thing is to help
the patient', 'we do not always have time to m a k e a differential diagnosis', 'diagnosis
is a matter of intuition'.
T h e following extracts from interviews show, however, that there does exist
an intermediate view of the importance of diagnosis: 'anamnesis and talking to the
patient c o m efirst,and then w e go on to the laboratory tests', 'anamnesis gives us a
picture of the patient's psycho-social background, and then w e are guided by the
scientific findings'.

Therapy and medication

It emerges clearly from the interviews that therapy and diagnosis are complementary.
Doctors w h o regard diagnosis as all-important apply comparatively rigid therapy
patterns, while others adapt their therapy strategy to the individuality of the patient.
T o illustrate the attitude which gives priority to therapy: 'therapy is an art',
'the choice of therapy follows naturally from one's contact with the patient', 'one
must be adaptable in prescribing therapy, for this depends on the patient', 'each
patient must be treated differently'.
 General practitioners in Switzerland 521

The doctors w h o are more inclined to apply a hard and fast pattern give their
reasons in the following words: 'the therapy is prescribed in the light of one's store
of knowledge, it is something one has learnt', 'diagnosis is more important than
therapy', 'we apply the therapy indicated by our diagnosis'.
It can be said that the approach to therapy is closely related to the question of
medication. The doctors interviewed regard prescription as an important stage of
consultations. It is a highly significant function in the eyes of both doctors and
patients. Several doctors express the view that 'the doctor is in fact the medicine',
or that 'the doctor is more important than the medicine'. But doctors in general
acknowledge that ' w e are often induced by our patients to prescribe medication' or
that 'patients are unwilling to go away empty-handed'. The problem of the quantity
of medicines absorbed is a particular cause for concern a m o n g doctors. These are
their feelings on the subject: 'a good doctor uses only a few medicines, but he is
aware of their eifects and knows h o w to handle them', 'we cannot be familiar with all
the medicines on the market and only a small number should be used', 'if you are
sure of your diagnosis, you can prescribe one specific remedy'. However, these
good intentions are not always put into effect. Doctors have noticed that the
prescription tends to be longer w h e n they have not had enough time to enter into a
dialogue with their patient, for in m a n y cases 'by talking to the patient, a lengthy
prescription could have been avoided'. Doctors become 'prescription writers' when
they give way to all the pressures that are brought to bear on them: the patient's
expectations and demands, their duty to relieve and remove distressing symptoms
rapidly, the difficulty of communicating with patients, or simply the limited time
available for each patient in surgery hours. Outside the consulting-room, another
factor plays a not inconsiderable role in prompting doctors to m a k e out lengthy
prescriptions, and that is the intensive propaganda from pharmaceutical labora-
tories. This problem does not lie within the scope of this survey. The expressions
used by the doctors in their interviews are set out in Table 1.

TABLE 1

Reception Diagnosis Therapy

Scientific Scientific Is indicated by the diagnosis

Competent Is a matter of training Rigid pattern
Conscientious Learnt to m a k e a diagnosis Medicines sparingly
prescribed (one specific
prescription)
Forceful A good clinical sense Knowledge of medicines and
h o w to handle them
Paternalistic Intuitive Prescription intended to treat
symptoms
Experienced Rapid diagnosis
Impatient Laboratory tests Prescription intended to
reassure patients
522 Andrs November

( T A B L E 1 cont.)

Reception Diagnosis Therapy

Timid
Subjective and objective data Wants to give relief/help
Irresolute/pessimistic
Patient Anamnesis/discussion Medicine is an art
A good clinical sense Follows naturally from
contact with the patient
Tries to establish contact Individualized diagnosis Explanation of prescriptions
and treatment
Reassuring Treatfirstand diagnose later Psychotherapy
Persuasive Therapy depends o n the
patient
Takes trouble to explain
Spends time with patients
Inspires confidence
Familiar
Assumes responsibility for the
patient
Invests a great deal in the
doctor-patient relationship
F o r m s a bond with his patients

If we simply classify these comments w e receive the general impression that

the doctors' behaviour can be represented in diagrammatic form as an axis with,
at one extreme, a tendency to stress medical values, and at the other, a tendency to
stress the patient's personality.
Tendency towards
medical values

Diagnosis

Therapy

Tendency to stress
the patient's personality

Thus, each doctor's behaviour varies according to his w a y of reacting to the basic
dialectical conflict between the claims of the illness and those of the patient. Should
the ailment be treated by drawing o n all the resources at the disposal of medical
science, or should the emphasis be laid on getting to k n o w the patient and applying
 General practitioners in Switzerland 523

medical science only in so far as this seems appropriate in view of the personality
of the patient? This conflict occurs in every consultation. Its essence is reflected in
three pairs of relationships: the doctor-patient relationship, which determines the
quality of the initial contact, the illness-patient relationship, which determines the
diagnosis, and lastly the medication-patient relationship, which determines the
therapy. T h e medical practitioner's work is centred on the patient, of course, but
paradoxical though it m a y seem, the more he avails himself of the powerful means
offered by medical science, the less he takes into consideration the patient's person-
ality as a whole.
This semantic analysis of the interviews only gives, in fact, an incomplete
picture of the doctor's real position with regard to his consulting-room work, for it
makes an artificial distinction between three of its aspects which are, in fact, closely
linked. A coherent view of what a consultation involves in practice can only be
obtained by examining the interrelation between the three.

Factor analysis of associated data

Since a conventional analysis of the different variables taken separately does not
throw full light o n a practitioner's behaviour in his consulting-room work, the
research team proceeded to m a k e a factor analysis, as it is one of the methods of
examining the interdependent structure of data collected during interviews (multi-
varied analysis). In the qualitative phase of the survey, the expressions extracted
from the interviews constituted the variables that were subjected to a factor analysis.
Factor analysis m a k e s it possible to reduce the data collected from our population
of medical practitioners; it establishes the set of correlations existing between
variables and defines the underlying multidimensional structures of the variables.
The factor obtained is a synthetic variable which is not directly observable during
the analysis of the interviews but is induced from the variables observed. If it is
correctly interpreted, the factor becomes a yardstick by which a set of data can be
measured. 6
B y calculating coefficients of correlation, the number of variables was brought
d o w n to twenty-four (see Table 2).
A positive correlation was found between the following variables: 'competent/
well-trained' and 'spends time with patients'/'comprehensive diagnosis'/'knows his
medicines' (correlation 0.3111); 'takes the initiative' and 'communicative'/'per-
suasive'/'laboratory tests' (correlation 0.3112).
T h e correlation calculated between variables confirms, in statistical terms,
some of the observations m a d e at the qualitative stage. T h e analysis of multivaried
data brings us nearer to understanding the behaviour patterns of doctors. B y a series
of calculations w e find a n u m b e r of factors (i.e. a linear combination of variables)
which are n o longer in correlation, andfiveof which are statistically significant.
524 Andrs November

TABLE 2. List of main variables and their frequency of occurrence in interviews

Frequency Fre<!
Variables Variables
(%) (%)

Competent/scientific/well-trained 35 A i m s at comprehensive therapy/

Impatient 11 treatment c o m e s first 43
Takes the initiative/acts swiftly 22 Treats causes 15
Communicative/persuasive 25 Psychosomatic treatment 25
Tries to establish contact/inspires C o m p l e m e n t a r y treatment given in
confidence 39 addition to medication 20
W a n t s to give relief 9 Uses a wide range of medicines 30
Intuitive 34 A c c u s t o m e d to using only a few
Family doctor 16 medicines that h e k n o w s h o w to
Objective diagnosis/according to handle 34
set patterns 44 Uses very active medicines 30
Comprehensive diagnosis/broad Prescribes few or n o medicines 37
diagnosis 59 T h e doctor is the medicine 18
Laboratory tests 8 Spends time with patients 57

T h e main components of thesefivefactors are:

Factor 1: 'takes the initiative'/'forful'/'communicative'/'persuasive'.
Factor 2: 'spends time with patients'/'Hstens to his patients'.
Factor 3: 'psychosomatic treatment'/'prescribes moderately'.
Factor 4: 'competent'/,well-trained'/'experienced'/'objective diagnosis'.
Factor 5: 'tries to establish contact'/'inspires confidence'.
T h e main components can be interpreted as axes in the space of the variables and it
is precisely this interpretation that characterizes a doctor's behaviour w h e n seeing a
patient. A s the multivariate analysis reveals, a consultation does not consist of a
succession of stages, i.e. reception-diagnosis-therapy; furthermore, the idea that
there are t w o distinct categories of doctors, one inclined to lay stress o n medical
values, and the other o n the patient's personality, should be modified to allow for
less polarized attitudes.
A s a result of the analyses, it can be seen that a consultation is composed of
five synthetic variables: (a) to what extent the doctor takes the initiative; (b) h o w
m u c h time he can afford to spend; (c) the treatment prescribed; (d) the doctor's
medical training; and (e) his contact with his patients.
Each consultation proceeds according to a pattern combining these variables,
in terms of which the practitioner's behaviour can be defined. W e are sure that w e
are dealing here with the underlying structure of consultations, for it differs from the
table drawn u p on the basis of the expressions used during the interviews and the
observations m a d e o n the doctors' behaviour.
 General practitioners in Switzerland 525

A medical consultation is a social act

T h e use of complementary qualitative and quantitative methods enables us to gain
m o r e insight into the real nature of a consultation. T h e five synthetic variables
(factors) that m a k e up the structure of a consultation can be described as personality
variables (forcefulness/initiative and capacity for communication) or as professional
variables (training and therapy). T h efifthvariable, namely, the time factor, is an
exogenous variable in relation to the others, which are inherent in the exercise of the
medical profession, including consulting-room work.
The w a y in which thefivefactors enter into a consultation can be seen from
Figure 1.
This method of conducting our research leads us to see the problem in a n e w
light: time is the all-important factor in a consultation. T i m e dictates whether or not
a doctor can talk to his patients and what therapy strategy he will adopt (how m u c h
medication or psychotherapy he will prescribe).
This finding shows that Eric Martin has good reason to protest against the
view that there are 'two categories of medicine', with scientific medicine o n the one
hand and h u m a n medicine o n the other.8

Patients need a doctor w h o listens to them and knows how they live; their problems rarely
call for complicated laboratory tests or examinations by means of sophisticated equipment.
The patient today wants a doctor in w h o m he can confide, regarding him as the guardian
of his health. Every trend in modern medicine should be directed towards the development
of a well-adapted type of health care, which means that it should bring laboratory tests
into line with the necessity of making a diagnosis and prescribing a course of treatment.

A similar view is expressed as follows in an article written by a medical practitioner:

This [medical] art used to consist in personalizing consulting-room work, the medical m a n
engaging with the sick m a n in an uninhibited dialogue in which he took time on each
occasion to look after the soul as well as the body, for one depends on the other. But the new
social ideology becoming prevalent today is in a fair way to undermine this basis of

Doctor's Medical
personality training
Accessibility/ C o m p e tence
contact

Treatment ^1
1^-

FIG. 1.
526 Andrs November

medical care. The m a n behind the desk, overworked and submerged beneath ever-
increasing piles of paperwork, w h o is supervised and controlled at every stagefrom
diagnosis to therapyby government departments, thereby losing all personal sense of
initiative and responsibility, this shadow of a doctor is clearly no longer capable of coping
with the distress and growing solitude of the human beings around him.
A n d further on in the text the doctor's identity is described in the following words: 7
he regards himselffirstand foremost as an honest worker whose job it is to look after
unstable, often ungrateful and rather hysterical human beings; he does it conscientiously,
to the best of his ability and with the grace of G o d or, as w e may prefer to say, given time,
patience and a favourable probability factor.
The introduction of the time factor puts a medical consultation into its sociological
context and converts it into a social act. Time is the main factor linking it with the
social environment. T h e sociological conditions prevailing today m a k e time a
scarce commodity: doctors d o not have the time to spend on long consultations in
order to explore their patients' personal problems. They have to see an ever-
growing number of patients and, furthermore, find little time to increase their o w n
knowledge and keep u p to date. W e shall not dwell here on the problem of their
remuneration, except to say that it is a well-known fact that doctors are under
constant pressure to earn more and maintain their social status.
Patients today are also pressed for time, d e m a n d instant relief from suffering,
and will not accept long courses of treatment unless there is no other hope of getting
better. But the only w a y for them to avoid taking medicines and undergoing costly
treatment is to be patient and be prepared to endure pain, which they are unwilling
to do; instead, they expect the doctor to speed up the curative process and to stop
pain quickly.
In conclusion, w e must stress that the research undertaken by the interdisci-
plinary team was confined to investigating the consulting-room work of doctors, for
m a n y studies have been produced on the attendant circumstances, such as the
training of doctors, their lifestyle and their social origins. N o thorough study has
yet been m a d e on what happens during the consultation itself, although this is the
focal point of a doctor's activity. Another essential point to note is that the research
was carried out by a team of non-medical sociologists to find out more about
doctors' problems through interviews with doctors. A serious pitfall was thus
avoided in exploring afieldwhich had hitherto been the preserve of members of the
profession, doctors speaking to doctors. In this case, the doctors still have the floor
and express their o w n views, but the recording and analysing of what they have to
say are in the hands of non-medical sociologists. Lastly, the methodology chosen has
enabled the team to contribute towards a better understanding of the practical
problems of the medical profession, and has paved the way for future research
(mainly typological).
[Translated from French]
 General practitioners in Switzerland
Notes
1
The research team was composed of Robert Cey-
Bert, Director of Research at the Institut de
4
Recherches de Communication et de Moti-
vation, w h o was in charge of the survey,
Andrs Krffy, research worker at the Depart-
ment of Sociology of the University of
Geneva, w h o was responsible for the quanti-
tative analysis, and the author, w h o was
5
entrusted with the co-ordination of the
project.
2
See Demographie Mdicale en Suisse (Sant Publique
6
et Prospective 1900-1974-2000), Lausanne,
Office Statistique de l'tat de Vaud, 1976,
7
286 p . , which covers all aspects of medical and
public health services in Switzerland.
3
The sample was composed of 180 doctors selected
527
at random from the rolls of the Swiss Medical
Yearbook, 1975 edition.
cf. H . L e Porrier, Le Mdecin Aujourd'hui, Paris,
Payot, 1976, 183 p . ' L e Mdecin Gnra-
liste de Demain' (Round Table conference
convened in Montreux o n 12 June 1975);
Mdecine et Hygine, Vol. 33, N o . 1163,
October 1975, p . 1389-94.
P . E . Green and D . S. Tull, Recherche et Dcisions
en Marketing, Grenoble, Presses Universi-
taires de Grenoble, 1974, 676 p .
Eric Martin, 'Il n'y a pas Deux Mdecines', La
Suisse (Geneva), 29 February 1976, p . 18.
J. Imfeld, ' L a Chute Vertigineuse du Mdecin
Suisse', Bulletin des Mdecins Suisses (Berne),
Vol. 57, N o . 10, p . 325 (author's italics).
The
social science
sphere
 The language of the social sciences
It has n o w c o m e to be widely recognized that the
development of the social sciences cannot be
considered independently of the particular cultural
traditions within which they develop. True, some of
the social sciences are m o r e bound by their cultural
traditions than others, but perhaps none is, from
this point of view, entirely free. While I shall draw
m y examples in what follows mainly from soci-
ology and social anthropology, m y argument will
apply in a broad w a y also to political theory and
political economy.
O f all the aspects of a cultural tradition
that impinge on the social sciences, the influence of
language is the most readily visible. Every social
science requires certain concepts, and appropriate
terms to describe these concepts. Durkheim, for
instance, felt that sociology could never truly ad-
vance until its concepts were clearly formulated
and its terminology fully standardized. Judged by
this test, sociology has not advanced very far, and
it m a y well be asked whether there is not some-
thing wrong with the test itself.
Disputes about the proper use of terms oc-
cupy a large place in disciplines like sociology, and
perhaps inevitably so. It has proved difficult, if not
impossible, to standardize, even within a single
linguistic tradition, the use of terms such as 'class',
'race' or 'nation'. The meaning has to be inferred
partly from the formal definition chosen by the
author and partly from the context of his argument.
This context includes the prevailing debate a m o n g
the various schools of thought to which the author
seeks to contribute; it usually extends beyond the
boundaries of academic social science into a wider
and m o r e amorphous intellectual milieu.
T h e wider intellectual milieu is in part
shaped by historical forces peculiar to each society
and culture. For this reason 'la classe ouvrire' and
'the working class' might not signify exactly the * ISSJ correspondent in Delhi.
Int. Soc. Sei. J., Vol. X X I X , N o . 3, 1977
Andr Bteille
same realities in France and in the United States
or, even, in Quebec and in Ontario. T h e problems
of translating into English such terms as 'sacr' or
'Stand' from what are, after all, closely related
European languages have bedevilled sociologists
for generations. H o w m u c h m o r e problematic it
must be to translate such terms into languages as
widely disparate as Arabic, or Bengali or Japanese.
I raise these questions because the problem
of translating, not merely terms but concepts and
perspectives, from one cultural setting to another
is an urgent one which has not received sufficient
attention from the profession. Even if n o ready
answers are available, these questions are worth
pondering over, if for n o other reason than that of
the great expansion in social science teaching and
research in the Third World, particularly in the
countries of Asia.
In the social sciences the professional litera-
ture which has an international market is in one
of the three or four major European languages
and, increasingly, everything of importance gets
translated into English, which has clearly emerged
as the dominant professional language. Indeed, if
what is originally published in s o m e other language
is not soon enough translated into English, it is not
likely to acquire great importance in the profession
as a whole. This is widely recognized by scholars
whosefirstlanguage is other than English, though
not always openly admitted.
English (or French or G e r m a n ) is not the
first language in m a n y countries where the social
sciences are rapidly expanding; sometimes it is not
k n o w n at all well to those w h o c o m e to the uni-
versities for advanced training in these subjects.
For this reason translations have to be produced in
 532
the languages actually in use. This is n o w a matter
of some importance in a country like India where
there are several regional languages into which the
literature has to be translated. The government
plays a major part in organizing this effort through
committees and panels of experts w h o formulate
the major principles of translation, put together
glossaries of terms and select the texts for trans-
lation. It would be worthwhile for scholars from
different countries which face similar problems to
exchange notes about the directions actually taken
by such efforts and their results.
The general feeling in India seems to be
that the quality of the translations, at least in the
case of sociology, is not very high. S o far these
translations are meant mainly for students and
most of them are textbooks. For most Indian
professional social scientists the language of pub-
lication is still English. S o m e efforts are being
m a d e to publish professional journals in Hindi
and other Indian languages, but in sociology at
least these often contain papers which have been
previously published in English.
Until ten or fifteen years ago English was
virtually the only language of higher education in
India. This is n o w changing, and English has to
compete increasingly with Hindi and other Indian
languages. W h e n the m e d i u m of instruction
changes, the content of education, particularly
in the social sciences, cannot remain wholly
unchanged. Will those w h o learn sociology through
Hindi (or Bengali or Tamil) acquire exactly the
same intellectual perspective as those w h o learn
it through English? W h a t will be the implications
of the coexistence of these alternative perspectives
for the development of a truly comparative
sociology?
Sociologists and social anthropologists
outside Europe and America are becoming incres-
ingly aware of the fact that a truly comparative
sociology, based on a reciprocity of perspectives,
does not exist, and that what passes for compara-
tive sociology is too closely involved in the
definitions, concepts and perspectives of a par-
ticular type of society and culture. The debate over
concepts and theories relating to 'progress',
'development' and 'modernization' makes this all
too clear to sociologists and political theorists in
Asian countries and elsewhere. This debate will re-
main sterile until and unless alternative theoretical
perspectives, based on different historical experi-
ences, are treated with equally serious attention.
Clearly, alternative perspectives in the
social sciences cannot develop merely through the
translation of English textbooks into Indian and
other Asian languages. N o r is it true that this is all
that is produced in these countries by way of social
science literature. In India a certain amount of
original writing in the social sciences has been
attempted in languages like Bengali and Marathi.
O n e m a y mention Irawati Karve and N . K . Bose,
two of India's leading social anthropologists, w h o
wrote respectively in Marathi and Bengali, in
addition to writing in English.
Several South Asian languages have a rich
body of literature relating to social thought. O n e
of these is Bengali, which is spoken by over
100 million people in both India and Bangladesh.
In India the new learning had an early start in
Bengal, and m a n y interesting tracts on social
questions were written in Bengali by nineteenth-
century thinkers. Thefirstgeneration of Bengali-
speaking professional social scientists wrote
mainly in English, but also in Bengali. O n e tends
to forget that it was not only possible, but perfectly
respectable, to write sociology in the ordinary
m a n ' s language until as recently as forty or fifty
years ago, so that Indian sociologists could be
ambidextrous, writing in both English and then-
native language.
All this changed rather quickly in the years
following the Second World W a r . Sociology
became increasingly preoccupied with its pro-
fessional image,firstin the United States, then in
Western Europe and soon afterwards in the world
as a whole. In order to keep one's place in the
profession one had to write in a certain style and
to show one's familiarity with a certain code. It
became increasingly difficult to adapt the non-
European languages to this new style in a creative
way. Thus, while there is m u c h textbook writing
in the Indian languages today, few scholars w h o
wish to m a k e a mark in the profession venture to
write in any language other than English. Perhaps
the way out of this dilemma would lie in a recon-
sideration of basic issues and problems in such
terms that creative writing becomes possible once
again in an idiom which is not too far removed from
c o m m o n understanding, whether the language
chosen is English or Bengali, Arabic or Japanese.
Perhaps it is only on this basis that a true reci-
procity of perspectives can emerge.
 The value of citation indexesa comment
John Fletcher, reviewing secondary information
services for economists in this Journal, states that
Current Contents Social and Behavioural Sciences
(CCSBS) is 'rather expensive'.1 Such statements
usually evoke a scale. I understand someone w h o
suggests that a Rolls Royce is rather expensive.
W h a t scale is being evoked by Fletcher? Equally
arbitrarily Nina Matheson, after a trial in which
92 per cent of users decided to continue with
Current Contents, says 'relative economy is the
primary advantage of this type of current aware-
ness'.2 I could go further and suggest that since
CCSBS covers a range of disciplines from econ-
omics, political science, and labour relations to
environmental studies, sociology and psychology,
the relative cost to a multidisciplinary library is
low. Admittedly I have evoked s o m e kind of
scalea researcher might think in terms of time
saved w h e n keeping up, but the fact is that I do
not k n o w the value of a unit of information per
selike everyone else I cannot even define it.
Even so information is perceived by m a n y
to possess extraordinary value. Thus E . B . Parker,
under the heading 'Information is Power', says:3
The difference between Orwell's 1984 and a hypo-
thetical participatory democracy lies in the question
of w h o controls the sending and receiving of infor-
mation . . . eventually economic theorists m a y be able
to devise an economic theory appropriate to the
information age.
Meanwhile, w e information protagonists are faced
with the problem of arguing the benefits of an
intangible resource in difficult times w h e n funds
are more likely to be allocated to activities with
tangible and easily measured outcomes. These are
the reasons w h y I deprecate the phrase 'rather
expensive'.
I also find it quite extraordinary that
int. Soc. Set. J., Vol. X X I X , N o . 3, 1977
A . E . Cawkell*
Fletcher omits to mention The Social Sciences
Citation Index (SSCI) anywhere in his article,
particularly after having said (p. 564) 'The most
frequently mentioned (by economists) methods
for locating references were references from other
sources, consulting an expert etc'
SSCI is the reference source par excellence.
W h e n the Science Citation Index, its predecessor,
w a sfirstpublished in 1961, it w a s foreseen that
citation indexes would be useful in the social
sciences4 and the SSCI followed from 1970
onwards.
A citation index provides access to a net-
w o r k of articles of the general form shown in
Figure 1.
T h e literature of a particular subject,
represented by circles and shown within the dotted
line, is interconnected by citations shown as
arrows; thus article A contains a reference to
article B . T h e subject's 'core' literature merges
into an ill-defined fringe area of related subjects.
If the existence of one article in the network is
k n o w n , a citation index enables the remainder to
be found except for works which contain n o
references and are never cited. In view of Fletcher's
omission I shall attempt to explain, very briefly,
h o w this is done.
Say I a m interested in the subject ' W a g e
bargaining and inflation' and a m aware of w o r k
by L . Godfrey in this area. T h e Citation Index
section of the SSCI is arranged alphabetically by
cited author and L . Godfrey's works which were
cited in 1974 are shown in Figure 2.
Citing items in this section such as the
articles by Mulvey, Parkin and Rothschild are
* Director of research, Institute for Scientific Infor-
mation, 132, High Street, Uxbridge, Middlesex,
U B 8 1 D P (United Kingdom).
 534

current articles indexed by the publishers, the
Institute for Scientific Information.6 These articles
are listed in the associated 1974 Source Index of
the SSCI (see Figure 3).
A n y of this information might prompt the
next step in our searchusing the lists of references
contained in articles w e might be tempted to
obtain Milton Friedman's article. However, note
that a m o n g the twelve and thirty-eight references
respectively in the Mulvey and Parkin articles a
c o m m o n reference not only to Godfrey (of which
w e are already aware) but also to A . G . Hines. Let
us get more up to date and forsake the 1974 for the
1976 Citation Index. Part of the 1976 Hines entry
and two of the articles which cite him are shown
in Figure 4.

FIG. 1. Citation Network.

GODFREY L
71 CURRENT INFLATION
MULVEY C SCOT J POLI 21 1 74
73 EARNINGS CHANGES UK
PARKIN M NAT W BANK 1974 32 74
73 OXFORD B ECONOMICS S
ROTHSCHI. KW SCOT J POLI L 21 303 74

Fio. 2. Entry from 1974 Citation Index section of the SSCI.

 The value of citation indexesa comment 535

MULVEY C,
TREVITHI. JA - Some evidence on wage leadership
hypothesis.
SCOT J POLI 21(1) 1 74 12R.
Univ. Glascow, Glascow, Scotland
BLUM A 72 BRIT J INDUSTRIA MAR
BRECHLING FPR 72 U ESS DISC PAP
COWLING K 66 ER131 PAP
GODFREY L 71 CURRENT INFLATION
>HINES AG 71 CURRENT INFLATION
etc.

PARKIN M
United Kingdom inflation -pjlicy alternatives
NAT W BANK 1974(MAY) 32 74 . 38R
Manchester Univ, Manchester, England
ANDERSEN LC 72 ECON OMETRICS PRICE
FRIEDMAN M 68 AM ECONOMIC REV
GODFREY L 73 EARNINGS CHANGES UK
->HINES AG 64 REV ECONOMIC STUDIES 31 221
etc.

FIG. 3. Source index description of two of the articles which cite Godfrey.

The Goldstein article is virtually a review, into economics, politics, management science, so-
and the Laidler article is classified as such with ciology, etc. If an article nominally in the area of,
an ' R ' . All of the 407 articles which Laidler say, law, connects to the network it will be
cites are shown beneath the description of his found.
article in the 1976 Source Index (not shown in Finally the third section of the SSCI
Figure 4). system, The Permuterm Subject Index (PSI), m a y
W e have n o w located some of the articles be used as preferred. Words from the titles of all
in the network for this subject area as shown in source index articles are listed in this index in the
Figure 5. form shown in Figure 6. T h e author's n a m e
W e can continue this process, exploring enables the user to refer to the source index for a
fringe areas as desired since the SSCI is a complete description of the article.
multidisciplmary system not arbitrarily subdivided T h e PSI is an index to title word-pairs. All
 536

HIES AG
64 REV ECONOMIC
GOLSTEI. M INT MONETR 22 680 75
LAIDLER D ECON J ft 85 741 75
RHYS DG INT J SOC E 3 45 76
A. PART OF ENTRY FOR AG HINES FROM THE
1976 CITATION INDEX SECTION OF SSCI
(INCLUDES SOME LATE 1975 CTING ARTICLES)

GOLDSTEI. M
Wage indexation, inflation, and labour market
INT MONETR 22(3), 680-713, 75 78R
etc.
LAIDLER D
PARKIN M - Inflation survey
ECON J 85(340), 741-809, 75 R 407R
etc.
B. PART OF CITING ARTICLE DESCRIPTIONS
FROM 1976 SOURCE INDEX SECTION OF SSCI

FIG. 4. Entries from the 1976 SSCI.

words in titles co-occurring with 'inflation' appear
under the heading ' I N F L A T I O N ' . Thus, in the
1976 edition, all words in the Goldstein article
(for instance ' W A G E ' ) will appear in an ordered
list beneath that heading, followed in each case by
the author's name. For a more complete descrip-
tion of the article look under ' G O L D S T E I . M . '
in the 1976 Source Index. Similarly, all words co-
occurring with 'WAGE'including all words in the
Goldstein articlewill appear under that heading.
This index enables the more conventional
'word approach' to be used since any given word
or word pair will lead to all articles containing that
word in its title.
Alternative strategies for using the various
sections of the index either to find a few articles
or to carry out a comprehensive search have been
described elsewhere.6
 The value of citation indexesa comment 537

Fio. 5. Part of the literature network for the subject 'aspects of wage bargaining and inflation'.

INFLATION WAGE
ACCOUNTING CLARKSON GP ADMISSION VOLZKE H
PETRI E INFLATION DOELMAN JA
INDEXATION GOLDSTEI. M DRIEHUIS W
LABOUR GOLDSTEI. M GOLDSTEI. M
ROBINSON JF ETC.
MARKET GOLDSTEI. M
SURVEY LAIDLER D
WAGE DOELMAN JA
DRIEHUIS W
GOLDSTEI. M
ETC.

F I G . 6. Example of format of 1976 Permuterm Subject Index section of SSCI.

 538
Notes
1
J. Fletcher, 'Secondary Information Services in
Economies', Int. Social Sei. J., Vol. XXVIII,
N o . 3, 1976, p. 563-71.
2 5
N . W . Matheson, 'User Reaction to Current
Contents, Behavioural, Social and Manage-
ment Sciences',Bull.Med. Lib. Assoc., Vol. 59,
N o . 2, 1971, p. 304-21.
3
E . B . Parker, Background Report for Social Impli-
cations of Computer and Telecommuni-
cations, in OECD Informatics Studies II,
Paris, O E C D , 1976, p. 87-117.
* E . Garfield, Citation Indexing; a Natural Science
Literature Retrieval System for the Social
Sciences, A m . Behav. Sei., Vol. 7 N o . 10,
1964, p. 58-61.
Social Sciences Citation Index, Institute for Scien-
tific Information, Philadelphia, 1970, and
thereafter (thrice annually and annual
cumulation).
A . E . Cawkell, Search Strategy, Construction, and
Use of Citation Networks with a Socio-
scientific ExampleAmorphous, Semi-
conductors and S. R . Ovshinsky, J. Amer.
Soc. Inf. Sei., Vol. 25, N o . 2,1974, p. 123-30.
 Professional
and documentary
services
 Addition N o . 2 to the World
List of Social Science Periodicals
Prepared by the Service for the Exchange of Scien-
tific Information of the Maison des Sciences de
l ' H o m m e , Paris, for the International Committee
for Social Science Information and Documentation.

In view of the recent appearance of the fourth such specimen copies to: Service d'change d'In-
edition of the World List of Social Science Period- formations Scientifiques (attention M . Jean Viet),
icals (Unesco, 1976, 72 F), as thefirstvolume in a Maison des Sciences de l'Homme, 54 Boulevard
new series of directories under the general title ofRaspail, 75270 Paris Cedex 06 (France), or to:
'World Social Science Information Services', this Social Science Documentation Centre (attention
Journal will henceforth publish, twice a year, an Miss Ester Ronquillo), Unesco, Place de Fontenoy,
updating supplement of new periodicals. Unlike the 75700 Paris (France).
former annual feature under the heading of 'New These two services, in consultation with each
Periodicals', which has been appearing in these pages other, will determine whether a given periodical meets
since1968, containing notices of a broadly descriptive the criteria for inclusion in the supplements to the
character on all serials brought to the attention of World List of Social Science Periodicals or is to
Unesco's Social Science Documentation Centre, this be noticed under our 'Books Received' section.
new updating supplement contains notices in a format Corrections to entries already contained in the World
identical with the entries in the World List of Social List of Social Science Periodicals, fourth edition, or
Science Periodicals and selected according to the in these supplements thereto, can also be supplied to
same criteria. These criteria restrict the choice to either of the two services above. They will be
academic periodicals containing signed articles withinreflected in thefifthedition of the complete directory
the area of one of the major social sciences, or while being currently recorded in the D A R E Data
occasionally in peripheral areas of interdisciplinaryBank at Unesco.
endeavour such as biology or ecology, as well as in
As in the World List, entries are classified
information and library sciences. Periodicals not
under country codings in alphabetical order.
meeting these criteria but which nevertheless deserve
to be brought to the attention of our readers, will in
future be included in the quarterly 'Books Received'
section, under a special heading.
The format used here for individual entries
takes account of the guidelines established by the
International Centre for the Registration of Serial
Publications, set up in Paris as part of the UNISIST A R G
framework, and the rules set out by the International Argentina
Federation of Library Associations for the standard
international bibliographical description of serials. INTEGRACIN LATINOAMERICANA [Integr. latinO-
The present supplement covers the period since amer.] (Apr. 1976- )
November 1974, which served as the cut-off date for a I N T A L , Cerrito 264-20 piso, Buenos Aires,
the World List of Social Science Periodicals, fourth b Id. 12 p.a.
edition. c 100 p. 2-3 art. (10 p.): Economic integration,
In order to prepare valid data on new period- cooperation and development in Latin America.
icals, it is essential to examine specimen copies. We Research notes (10 p.). Inf. (10 p.). Critical reviews
therefore appeal to editors and publishers to send (3 p.). Documents (20 p.). Statistiques (5 p.).

Int. Soc. Sei. J., Vol. X X L X , N o . 3, 1977

 542
AUS
Australia
H E C A T E . A W o m e n ' s Interdisciplinary Journal
[Hecate] (1975- )
a Ed.: C . Ferner, P . O . Box 99, St. Lucia, Queens-
land, 4067.
b Every W o m a n Press, 94 Abercrombie Street,
Chippendale, N . S . W . 2008. 2 p. a.
c 100-120 p. 6-8 art. (2-10 p.): Interdisciplinary
studies on w o m e n : poems, women's place in
literature, criminology...
ISSN: 0311-4198
AUT
Austria
A F G H A N I S T A N J O U R N A L [Afghan. J.] (1974-
a Ed.: K . Gratzl, Graz.
b Akademische Druck und Verlagsanstalt, Auer-
sperggasse 12, Postfach 598, A-8011 Graz.
4 p.a.
c 40 p. 4-5 art. (5-8 p.): Anthropology, archi-
tecture, social sciences, economics, linguistics
concerning Afghanistan. Inf. (1 p.). Bibliogr.
(1/2 p.). Critical reviews (3 p.). Abstracts (1/2 p.).
N . B . Art. in English, G e r m a n or French.
Reviews in German and in English.
C O L L O Q U I U M I N T E R N A T I O N A L E . Bulletin of the
ciety for H u m a n Ecology [Colloq. int.]
(Jul. 1976- )
a Ed.: H . Knotig, Karlsplatz 13, A-1040 Wien.
b Georgi Publishing C o m p a n y , C H - 1 8 1 3 St-
Saphorin, Switzerland. 6 p.a.
c 45-50 p. 2 art. (8-12 p.): H u m a n ecology.
Research notes (20 p.). Inf. (20 p.). Bibliogr.
Critical reviews (2-3 p.). Abstracts.
N . B . Art. in English, French or German
with translation or summaries in the other two
languages.
ISSN: 0304-2863
EMPRICA. Zeitschrift des sterreichischen Instituts
fr Wirtschaftsforschung [Emprica] (1974- )
a sterreichisches Institut fr Wirtschaftsfor-
schung, A-1103 Wien, sterreich Arsenal,
Postfach 91.
b Gustav Fischer Verlag, 7 Stuttgart 72 (Hohen-
heim), Wollgrasweg 49. 2 p.a.
QP
c 148 p. 4 art. (30 p.). Austrian economics and
economic policy. Research notes (30 p.).
ISSN: 0340-8744
EMPIRICAL E C O N O M I C S . A Quarterly Journal of the
Institute for Advanced Studies. Vienna [Empi-
ric. Econ.] (1976- )
a Institute for Advanced Studies, Stumper-
gasse 56, A-1060 Vienna. Ed.: E . Frst.
b Id. 4 p.a.
c 80 p. 3-5 art. (5-15 p.).
BRA
Brazil
T.D.I. Teoria, Debate e Informao [T.D.I.] (Apr.
) 1976- )
a Associao Regional dos Socilogos (A.R.S.),
Avenida Braz de Aguiar, 85, Sala 003, Belm.
Ed.: E . R a m o s de Castro, J. M . Klantan de
Arajo.
b Id. ? p.a.
c 130 p. 5-7 art. (5-20 p.): Sociology of North-
eastern Brazil. Debates. Inf. (4-6 p.).
CAN
Canada
So-
CANADIAN JOURNAL OF EDUCATION [Canad. J. Edite]
(1976- )
a Canadian Society for the Study of Education,
Box 1000, Faculty of Education, The University
of Alberta, Edmonton, Alberta T 6 G 2 G 5 .
b Id. 4 p.a.
c 85-100 p. 6 art. (20-25 p.): Educational sciences.
Bibliogr. (1 p.). Author index and dictionary
index.
N . B . The art. are in French or in English.
ISSN: 0380-2361
LABOUR/LE TRAVAILLEUR. Journal of Canadian
Labour Studies/Revue d'tudes Ouvrires C a -
nadiennes [Labour] (1976- )
a Committee on Canadian Labour History. Ed.:
G . S. Kealey, Department of History, Dal-
housie University, Halifax, N o v a Scotia.
b Id. 1 p.a.
 Addition No. 2 to the World List
of Social Science Periodicals
c 200 p. 8 art. (25 p.): Interdisciplinary study of
Canadian labour history. Critical reviews.
N . B . Art in English or in French. The review
also publishes a biannual BULLETIN.
ISSN: 0700-3862
CHE
Switzerland
F A M I L I E N D Y N A M I K . Interdisziplinre Zeitschrift fr
Praxis und Forschung [Familiendynamik] (May
1976- )
a Institut fr Ehe und Familie, Wiesenstrasse 9,
C H - 8 0 3 2 Zrich.
b Ernst Klell Verlag, Rotebhlstrasse 77, Post-
fach 809, D 7000 Stuttgart 1. 4 p.a.
c 80 p. 4-5 art. (10-25 p.): Sociology, pathology
and therapy of the family and its members,
couple and family dynamics. Inf. Bibliogr. Critical
reviews. Abstracts. Table. Author index and subject
index.
N . B . Summaries of the art. in English.
COL
Colombia
ESTUDIOS D E F O B L A C I N [Estud. Poblacin] (Jan.
1976- )
a Asociacin Colombiana para el Estudio de la
Poblacin, Carrera 23 no. 39-82, Bogota D . E . 1.
Ed.: R . Salazar Santos,
b Id. 12 p.a.
c 80-90p. Notes and inf. on the programmes, the
research and the experiments conducted in b Hans Richarz, Postfach 6053, D 5205 Sankt
Latin America on the situation of the population.
CRI
Costa Rica
A V A N C E S DE INVESTIGACIN [Avances Invest.] (1975-
) SBMiosis. Zeitschrift fr Semiotik und ihre A n w e n -
a Instituto de Investigaciones Sociales, Facultad
de Ciencias Sociales, Universidad de Costa Rica, a Ed.: E . Walther, Vorsteigstrasse 24 B , D . 7000
Ciudad Universitaria 'Rodrigo Faci', Apar-
tado no. 49, San Pedro de Montes de Oca, San
Jos. Ed.: V . Basanri.
b Id. Irr.
543
c 40-50 p. Each issue is devoted to the analysis of
a research in social science in progress in Costa
Rica.
CUB
Caba
REVISTA CUBANA D E ADMINISTRACIN D E SALUD
[R. cub. Adm. Salud] (1975- )
a Dir.: F. Rojas Ochoa, Instituto de Desarollo de
la Salud, Apartado 9082, L a Habana,
b Centro Nacional de Informacin de Ciencias
Mdicas, Calle 23 numero 177, entre N y O , La
R a m p a , Vedado, Apartado 6520, L a Habana.
4 p.a.
c 100 p. 8 art. (5-15 p.): Health administration in
Cuba, medical education, community medicine,
statistics, demography, sociology. Inf. Critical
reviews (4 p.). Graphs. Table. Subject index.
Author index.
DEU
Germany (F. R.)
C O M M U N I C A T I O N S . Internationale Zeitschrift fr
Kommunikationsforschung/International Jour-
nal of Communication Research/Revue Inter-
nationale de Ia Recherche de Communication
[Communications (Kln)] (1975- ) (1974: IN-
T E R N A T I O N A L E ZEITSCHRIFT FR KOMMUNIKA-
TIONSFORSCHUNG)
a Ed.: A . Silbermann, J. K . Meinel, Klner
Institute fr Massenkommunikation, Leybold-
strasse 62, 5 Kln 51.
Augustin 1. 3 p.a.
c 130 p. 7-8 art. (10-15 p.): Multidisciplinary
studies on all aspects of h u m a n communi-
cation. Mass media. Critical reviews (10 p.).
N . B . Art. in German, English or French with
summaries in the three languages.
ISSN: 0341-2059
dungen [Semiosis] (March 1976- )
Stuttgart 1-G. Deledalle, Place de l'glise,
34140 Montbazin.
b Agis-Verlag G m b h , Postfach 7, 7570 Baden-
Baden. 4 p.a.

544
c 65-80 p. 6-8 art. (10-15 p.): Historical and
applied study of C . S . Pierce's theory of signs.
Critical reviews (4-5 p.). Title index.
S T A D I O N . Zeitschrift fr Geschichte des Sports und
des Krperkultur/Journal of the History of
Sport and Physical Education/Revue d'Histoire
du Sport et de la Culture Physique [Stadion] France
(1975- )
a Ed. : W . Decker, M . L m m e r , Institut fr Sport- A U S T R I A C A . Cahiers Universitaires d'Information
geschichte der Deutschen Sporthochschule
Kln, Carl Diem W e g , D 5000, Kln 41.
b E . J. Brill, Oude Rijn 33a-35, Leiden, Nether-
lands. 2 p.a.
c 400 p. 10 art. (40 p.): History of sport and
physical education. Critical reviews (6 p.).
Graphs. 111. Table. Title index.
ZEITSCHRIFT F R B E V L K E R U N G S W I S S E N S C H A F T . D e - Bibliogr. (2 p.). Critical reviews and abstracts
mographie [Z. Bevlk.-Wiss.] (1975- )
a Bundesinstitut fr Bevlkerungsforschung,
Postfach 5528, 62 Wiesbaden. Ed.: H . W . Jr-
gens.
b Deutsche Verlags-Anstalt G m b H , Postfach 209,
D - 7 0 0 0 Stuttgart 1. 4 p.a.
c 140 p. 5-6 art. (15-25 p.): D e m o g r a p h y .
Research notes (8 p.). Inf. (5 p.). Bibliogr. (2 p.).
Abstracts (5 p.). Author index.
N . B . Art. in G e r m a n or in English. Tables of
contents and summaries of the art. in English, in
G e r m a n and in French.
ZEITSCHRIFT FR HISTORISCHE FORSCHUNG. Viertel-
jahresschrift zur Erforschung des Sptmittel-
alters und der frhen Neuzeit [Z. hist. Forsch.] notes. Inf. Abstracts of memoirs (5 p.). Graphs.
(1974- )
a E d . : J. Kunisch, Blumenthalstrasse 19, 5000
Klnl.
b Duncker u n d H u m b l o t , Dietrich-Schfer-
W e g 9,1000 Berlin 41. 4 p.a.
c 140 p. 3 - 4 art. (20 p.): Political and social
history of the late Middle Ages and modern
times. Critical reviews (20 p.).
ISSN: 0340-0174
ESP
Spain
E S T U D I O S L A B O R A L E S [Estud. labor] ( M a y 1975-
a Instituto de Estudios Laborales y de Seguridad
Social, Ministerio de Trabajo, Madrid. Dir.:
E . Barrajo Dacruz.
m
b Id. irr.
c 170-180 p. 10-12 art. (10-20 p.): Labour law
and social security. Bibliogr.
FRA
sur l'Autriche [Austriaca] (1975- )
a Centre d'tudes et de Recherches Autrichien-
nes, Universit de Haute-Normandie, rue L a -
voisier, 76130 Mont-Saint-Aignan.
b Id. 2 p.a.
c 180 p. 5-8 art. (15 p.): Studies on Austria
(history, economics, sociology, politics, litera-
ture, arts). Research notes (5 p.). Inf. (5 p.).
(10 p.).
ISSN: 0396^590
C A H I E R S (LES) D E L ' A N A L Y S E D E S D O N N E S [C. Anal.
Donnes] (1976- )
a Dir.: J. P . Benzcri. Laboratoire de Statistique
de l'Universit Pierre et Marie-Curie, 4 place
Jussieu, 75005 Paris,
b Centrale des Revues Dunod-Gauthier-Villars,
B . P . 119, 93104 Montreuil Cedex. 4 p.a.
c 120 p. 6-7 art. (15-20 p.): Theory and appli-
cation of n e w statistical techniques (particu-
larly correspondence analysis) in the social and
natural sciences. Computer programs. Research
Table. N a m e and author index. Subject index.
N . B . Summaries of the art. in French and in
English.
I S S N : 0339-3097
I M P A C T . Revue Internationale d'Anthropologie Vi-
suelle [Impact. Revue int. Anthropol. vis.] (1975-
)
a E d . : J. Willemont, 66 rue de la Fontaine-au-Roi,
75011 Paris.
b Id. 4 p.a.
c 46-50 p.: Direct cinema: interviews, analysis
of films.. . . Photos.
)
P A I X E T C O N F L I T S . Cahiers d u G r o u p e de Sociologie
de la Dfense de l ' E . H . E . S . S . [Paix et Conflits]
(Dec. 1975- )
 Addition No. 2 to the World List
of Social Science Periodicals
a Groupe de Sociologie de la Dfense, cole des
Hautes tudes en Sciences Sociales, 54 Bd Ras-
pail, 75006 Paris.
b Id. 4 p.a.
c 15-20 p. 3-6 art. (2-4 p.): Studies concerning
defence problems, centered on political or
military topics.
P S Y C H A N A L Y S E A L'UNIVERSIT [Psychanal. Univ.]
(1975- )
a Laboratoire de Psychanalyse et de Psychopa-
thologie, U . E . R . Sciences Humaines Cliniques,
Universit Paris VII. Ed.: J. Laplanche.
b Editions Rplique, 9 rue Dupont-des-Loges,
75007 Paris. 4 p.a.
c 200-220 p. 8-10 art. (10-50 p.): Teaching
psychoanalysis at university level. Inf.
R E C H E R C H E S C O N O M I Q U E S E T SOCIALES. Notes, Cri-
tiques et Dbats [Rech. con. soc] (1976- )
a C . O . R . D . E . S . , Commissariat Gnral au Plan,
30 rue Las-Cases, 75007 Paris. Ed.: C . Matet.
b Documentation Franaise, 29-31 Quai Vol-
taire, 75340 Paris-Cedex 07. 4 p.a.
c 110 p. 4-5 art. (15-20 p.): Discussions and
debates on the research in progress at the
C . O . R . D . E . S . Meetings and conferences (25-
30 p.).
REVUE J U R I D I Q U E D E L ' E N V I R O N N E M E N T [R. jur. DISASTERS. T h e International Journal of Disaster
Environ] (1976- )
a Socit Franaise pour le Droit de l'Environne-
ment. Ed.: M . Prieur.
b Publications Priodiques Spcialises, 11 rue
d'Algrie, 69001 Lyon. 4 p.a.
c 90-100 p. 3-4 art. (5-10 p.): Environmental
law and economics. Jurisprudence (35-40 p.).
Documents (20 p.). Inf. (2-3 p.). Bibliogr.
(4-5 p.).
T R A V E R S E S [Traverses] (1975- )
a Centre de Cration Industrielle, Centre Natio-
nal d'Art et de Culture Georges-Pompidou,
28 rue des Francs-Bourgeois, 75003 Paris. E d . :
F. Mathey.
b ditions de Minuit, 7 rue Bernard-Palissy,
75006 Paris. 4 p.a.
c 140-160 p. 10-15 art. (10-20 p.): Attempt
at a 'transversal approach' to social objectives.
111.
545
GBR
United Kingdom
BRITISH J O U R N A L O F T E A C H E R D U C A T I O N [Brit. J.
Teacher Educ] (1975- )
a Ed.: E . Stones, School and Institute of E d u -
cation, University of Liverpool, 19-23 Aber-
cromby Square, Liverpool L G 9 3 B X .
b Methuen and C o . , North W a y , Andover,
Hampshire S P I O 5 B E . 3 p.a.
c 120-130 p. 8-10 art. (10-20 p.): Teacher
training. Critical reviews.
C O R E . Collected Original Resources in Education:
A n International Journal on Educational R e -
search Published in Microform [CORE] (1977-
)
a E d . : D . Cherrington, Department of E d u -
cational Studies, City of Burmingham Poly-
technic, 625 Chester R o a d , Sutton Coldfield,
W . Midlands,
b Carfax Publishing C o m p a n y , H a d d o n House,
Dorchester-on-Thames, Oxford O X 9 8J2.3 p.a.
c 1,000 p. 30-40 art.: Educational sciences. Table.
Title index. Subject index. Author index. Dic-
tionary index.
ISSN: 0308-6909
Studies and Practice [Disasters] (1977- )
a E d . : J. Seaman, London Technical Group,
Institute of Biology, 41 Queen's Gate, London
SW7 5HU.
b Pergamon Press, Headington Hill Hall, Oxford
OX3 O B W . 4 p.a.
c 75 p. 4 art. (5-12 p.): Multidisciplinary approach
to disasters; prevention and relief. Inf. (5-8 p.).
Correspondence. Critical reviews (6 p.). Bibliogr.
(2 p.).
ISSN: 0361-3666
E T H N I C G R O U P S . A n International Periodical of
Ethnic Studies [Ethn. Croups] (1974- ) (Incor-
porating: AFRO-AMERICAN STUDIES: 1970-73)
a Ed.: A . L . L a Ruffa, J. S. Saviskinsky, P. Rafti.
b Gordon and Breach Science Publishers Ltd.,
42 William IV Street, London W C 2 . 4 p.a.
c 80-100 p. 3-4 art. (10-20 p.): Ethnic groups:
new trends of research, new theories.
 546
E U R O P E A N L A W R E V I E W [Ewop.
1975- )
Law R.] (Nov.
a Ed.: A . Dashwood, School of European Studies,
Arts Building, University of Sussex, Brighton,
B N 1 9 Q N , Sussex,
b Sweet and Maxwell, North W a y , Andover,
Hants SP10 5BE. 6 p.a.
c 70-90 p. 2-3 art. (15 p.): European inter-
national law, legal aspects of European inte-
gration. Current survey of legal developments in
E . E . C . (30-40 p.). Critical reviews (2 p.). Title
index. Subject index. Dictionary index.
HUMAN RIGHTS REVIEW [Hum. Rights R.] (1976- )
a Ed.: J. E . S. Fawcett, 23 Hanover House,
St John's W o o d High Street, London N W 8 .
b Oxford Journals, Press Road, Neasden, Lon-
don N W 1 0 O D D . 2 p.a.
c 100 p. 2 art. (8-12 p.): H u m a n rights. Inf.
(50 p.). Documents (20 p.).
ISSN: 0308-0765
INDUSTRIAL ARCHAEOLOGY REVIEW [Industr. Ar-
chaeol. R.] (1976- )
a Ed.: J. Butt, Association for Industrial Archae-
ology.
b Oxford University Press, Press Road, Neasden,
London N W 1 0 O D D . 3 p.a.
c 96 p. 8 art. (10-12 p.): Industrial archaeology.
ISSN: 0309-0728
JOURNAL OF HISTORICAL GEOGRAPHY [/. hist. Geogr.]
(1975- )
a Ed. : J. Patten, School of Geography, Oxford,
b Academic Press, 24-28 Oval Road, London
N W 1 . 4 p.a.
c 100 p. 4 art. (15 p.): Review article (5 p.).
Critical reviews (10 p.). Abstracts (5 p.). Inf.
Maps. Graphs. Table.
b Id. 4 p.a.
M A R I N E P O L I C Y . Organization, Management and c 100 p. 4 art. (25 p.): Library history. Bibliogr.
Regulation of the Multiple Use of Ocean Space
[Mar. Pol.] (Jan. 1977- ) reviews (2 p.). Table. Title index, subject index and
a Ed.: T . Loftas, Little Steading, 58 Queens author index.
Road, Thame, Oxon O X 9 3 N Q .
b I.P.C. Science and Technology Press Ltd., NATIONAL LABOUR INSTITUTE. BULLETIN [Nat. Lab.
32 High Street, Guildford, Surrey. 4 p.a.
c 88 p. 7 art. (10-20 p.): Marine law, activities, a National Labour Institute, A . B . 6 Safdarang
conflicts, policies, development and resources.
Research notes. Inf. Bibliogr. Critical reviews.
QQ
Abstracts. Graphs. 111. Table. Title index. Subject
index. Author index.
R A D I C A L SCIENCE J O U R N A L [Radical Sei. J.] (1974-
)
a Ed.: P. Boys, G . Browning, C . Clutterbuck...
9 Poland Street, London W 1 V 3 D G .
b Id. 1 p.a.
c 110 p. 3 art. (20-30 p.): Political criticism of
scientific ideology and practice. Notes. Critical
reviews (10 p.). 111. issN: 0305 0963.
WEST (THE) AFRICAN JOURNAL OF SOCIOLOGY A N D
POLITICAL SCIENCB. A n International Quarterly
[ West Afr. J. Sochi, polit. Sei.] (Oct. 1975- )
a Ed.: J. Labinjoh, Department of Politics, Uni-
versity of Exeter, Amory Building, Exeter,
EX4 4PU.
b Eastern Press Ltd., London. 4 p.a.
c 100-110 p. 4-6 art. (12-20 p.): Sociological and
political science studies concerning Africa, by
African university professors and researchers. Criti-
cal reviews (20-25 p.).
BMD
India
L E G A L H I S T O R Y [Legal Hist.] (Apr. 1975- )
a Ed.: K . K . Roy, 55 Gariahat Road, P . O .
Box 10210, Calcutta 700 019.
b Id. 4 p.a.
c 100 p. 4 art. (25 p.): History of law. Bibliogr.
Research notes (1 p.). Inf. (1 p.). Critical
reviews (2 p.). Table. Title index, subject index and
author index.
LIBRARY H I S T O R Y R E V I E W [Libr. Hist. R.] (March
1974- )
a
Ed.: K . K . Roy, 55 Gariahat Road, P . O .
Box 10210, Calcutta 700 019.
Research notes (1 p.). Inf. (1 p.). Critical
Inst. B.] (1975- )
Enclave, N e w Delhi, 110016. Ed.: N . R . D e ,
S. Gakkhar
 Addition No. 2 to the World List
of Social Science Periodicals
b Id. 12 p.a.
c 30-40 p. 6-7 art. (4-6 p.): Labour problems:
law, organization... Institute news.
ISR
Israel
JERUSALEM (THE) JOURNAL OF INTERNATIONAL RE-
LATIONS [Jerusalem J. int. Relat.] (Fall 1975- )
a Leonard Davis Institute for International R e - a Ed.: E . Ribes, Universidad Nacional Aut-
lations, Hebrew University of Jerusalem. Givat
R a m , Jerusalem. Ed.: D . V . Segre.
b Id. 4 p.a.
c 100 p. 5 art. (10-20 p.): International relations.
Critical reviews (8 p.). Table. Author index.
ITA
Italy
GIORNALE ITALIANO DI PSICOLOGIA/ITALIAN JOURNAL
OF PSYCHOLOGY [G. ital. Psicol.] (1974- )
a Ed. : C . A . Urnilta. Universita di Padova.
b II Mulino, Via San Stefano 6, 40125 Bologna.
3 p.a.
c 130 p. 7 art. (15 p.): Psychology. Research
notes (10 p.). Critical reviews (20 p.). Table.
N . B . Art. in English, summaries in Italian.
LIE
Liechtenstein
INTERNATIONAL B A C K G R O U N D . A n International
Journal of Current, Political, Social and Econ-
omic Affairs [Int. Background] (1974- )
a Ed.: A . Fredborg, F . Andreen, 384, FL-9497
Triesenberg, Liechtenstein.
b Carfax Publishing Company, P . O . Box 7-356,
West Hartford, Conn. 06107, U . S . A . 10 p.a.
c 24 p. 5-6 art. (2-5 p.): International political
development, international economics. N a m e s
and subject indexes.
MEX
Mexico
N U E V A A N T R O P O L O G A [Nueva Antropol.] (1975- )
a Escuela Nacional de Antropologa e Historia,
547
Apartado Postal 11^*25, Mexico II, D . F . Ed.:
E. Stephan Otto,
b Id. 4 p.a.
c 100-110 p. 4 art. (25-30 p.): Anthropology:
re-defining its objectives and theoretical bases.
Critical reviews (5-8 p.).
REVISTA MEXICANA DE ANALISIS DE LA CONDUCTA/
MEXICAN JOURNAL OF BEHAVIOR ANALYSIS [R.
mexic. Anal. Conducta] (1975- )
n o m a de Mxico.
b Apartado Postal 69-716, Mexico 21-D.F. 2 p.a.
c 170-175 p. 10-15 art. (6-20 p.): Behavior
analysis. Comments.
MYS
Malaysia
N E G A R A [Negara] (1976- )
a Board of National Unity, Prime Minister's
Department, Malaysia,
b Id. 2 p.a.
c 38^K) p. 4-5 art. (5-10 p.): Race relations and
national unity problems in countries with
heterogeneous societies.
NGA
Nigeria
NIGERIAN JOURNAL OF INTERNATIONAL STUDIES [Ni-
ger. J. int. Stud.] (Jul. 1975- )
a Nigerian Institute of International Affairs,
Box 1727, Lagos.
b Id. 2 p.a.
c 120 p. 4-6 art. (10-15 p.): International re-
lations. Bibliogr. (4 p.). Critical reviews (1 p.).
PHI
Philippines
INITIATIVES IN P O P U L A T I O N . Quarterly Magazine of
the Population Center Foundation of the
Philippines [Initit. Popul.] (1975- )
a Population Center Foundation, Population
Center Foundation Building, South Superhigh-
way, Makati, Rizal. Ed.: V . G . Tirol.
 m
548

b P . O . Box 2065, Makati Commercial Center,
Makati, Rizal 3117. 4 p.a.
c 50-60 p. 5-7 art. (5-10 p.). Demography,
family planning . . . Bibliogr. Correspondence.
111. Graphs.
c 100-120 p. 7-8 art. (12-20 p.): Contradictions in
the development of the Third World countries,
more particularly in Tanzania and neighbouring
countries. Critical reviews (2-3 p.).

USA
PNG United States
Papua-New Guinea
ABSTRACTS O F P O P U L A R C U L T U R E . A Quarterly
Publication of International Popular Pheno-
A D M I N I S T R A T I O N F O R D E V E L O P M E N T . Journal of the
Administrative College of Papua and N e w mena [Abstr. popul. Cult.] (Oct. 1976- )
Guinea (Adm. Develop] (Jan. 1974- ) a Ed.: R . B . Browne, The Center for the Study of
a Administrative College, P . O . Box 1216, Boroko. Popular Culture, Bowling Green University,
b Id. 2 p.a. Bowling Green, Ohio 43403.
c 65 p. 5 art. (8-10 p.): Development of Mela- b Bowling Green University, Popular Press, Id.
nesia: administration, training, sociology, econ- 4 p.a.
omics . . . Research notes (4 p.). Bibliogr. Critical c 200 p. 2,100 abstracts of art., mainly chosen
reviews (6 p.). from American reviews, concerning popular
culture (television, circus, carnavals, rural and
urban life, counter culture, sport, women's stu-
dies . . . ) . Title index. Periodical index (approxi-
SEN mately 200 titles). Subject index.
Senegal
AMERICAN BAR FOUNDATION RESEARCH JOURNAL
E N V I R O N N E M E N T AFRICAIN. Cahiers d'tude du [Amer. Bar Found. Res. /.] (Dec. 1975- )
Milieu et d'Amnagement du Territoire [Envi- a American Bar Foundation, 1155 East 60th
ron, afr.] (1975- ) Street, Chicago, 111. 60637. Ed.: S. L . Kimball,
a Programme 'Formation pour l'Environne- b Id. 4 p.a.
ment' ( E N D A ) , B.P. 3370, Dakar. Ed.: J. Bu- c 339 p. 4-6 art. (30-60 p.): Problems of legal
gnicourt, P . Langley, L . Mhlanga. professions. Functioning of legal institutions.
b Id. 4 p.a. L a w . Table.
c 100 p. 8 art. (10-15 p.): Ecology, environment,
regional planning and development in Africa APPLIED PSYCHOLOGICAL MEASUREMENT [Appl. psy-
(health, housing, drought, starvation . . . ) . Docu- chol. Measur.] (1977- )
ments. Inf. Critical reviews (6 p.). Review of a Ed.: D . J. Weiss, N 660 Elliott Hall, 75 East
reviews (6 p.). M a p s . Graphs. III. Title and author River Road, University of Minnesota, Minnea-
index. polis, Minn. 55455.
N . B . Art. in English or French. b West Publishing Company, 50 W . Kellogg
Boulevard, Saint Paul, M N 55102. 4 p.a.
c 160 p. 12 art. (12 p.): Methodology and
application of techniques of psychological
TZA measurement. Research notes (2 p.). Inf. (2 p.).
Tanzania Critical reviews (6 p.). Abstracts of computer
programs (6 p.). Tables and graphs. Table.
UTAFITI. Journal of the Arts and Social Sciences
[Utafiti] (1976- ) B I O F E E D B A C K A N D S E L F - R E G U L A T I O N [Biofeedback
a Faculty of Arts and Social Sciences, University Self-Regul.] (1976- )
of Dar es Salaam, East African Literature a Ed.: J. Stoyva. Department of Psychiatry,
Bureau, P . O . Box 30022, Dar es Salaam. Ed.: Box C 258, University of Colorado Medical
Y . Tandon, Center, 4200 East Ninth Avenue, Denver,
b Id. 2 p.a. Colo. 80220.
 Addition No. 2 to the World List
of Social Science Periodicals
b Plenum Publishing Corporation, 227 West
17th Street, N e w York, N . Y . 10011. 4 p.a.
c 100 p. 6 art. (10 p.): Self-regulation techniques
of physiological activities and behavior. Psy-
chology, psychiatry, physical and psychosomatic
medicine, cybernetics. 2-3 case reports (10 p.).
Critical reviews (5 p.). Graphs. Table. Author
index. Subject index.
C O M M U N I C A T I O N [Communication] (June 1974- )
a E d . : L . Thayer, P . O . B o x 8, Williamsburgh,
M a 01096.
b Gordon and Breach Science Publishers,
41/42 William IV Street, London W C 2 ,
England. 2 p.a.
c 130 p. 9 art. (15 p.): Communication in h u m a n
relations: conceptual, theoretical and phil-
osophical approaches to a particular topic.
Notes. 111.
COMMUNITY JUNIOR COLLEGE RESEARCH QUARTERLY
[Commun. Junior Coll. Res. Quart.] (Sept. 1976-
) ton R P - 1 0 , Seattle, W a 98195.
a Adult Education Program, Department of
Secondary, Post-Secondary Education, Virgi-
nia C o m m o n w e a l t h University, Richmond, V a .
b Hemisphere Publishing Corporation, 1025 Ver-
mont Avenue, N . W . , Washington, D . C . 20005.
4 p.a.
c 112 p. 6-7 art. (10-15 p.): Post-secondary edu-
cation in the United States. Research notes and
critical reviews (9 p.). Bibliogr. (1 p.). Abstracts
(1 p.). Graphs. 111. Table. Subject index.
COMMUNITY MENTAL HEALTH REVIEW [Commun.
ment. Health JR.] (1976- )
a E d . : H . Gottesfeld, L e h m a n College, City
University of N e w York.
b Haworth Press, 174 Fifth Avenue, N e w Y o r k ,
N . Y . 10010. 6 p.a.
c 25-30 p.: Mental health and community: 1 re-
view art. (10 p.). Abstracts (10 p.). Inf. (3 p.).
Critical reviews (4-5 p.).
COMPUTERS A N D EDUCATION. A n International
Journal [Computers and Educ] (1976- )
a Ed.: A . A . Pouring, D . F . Rogers, Aerospace
Engineering Department, U . S . Naval A c a d e m y ,
Annapolis, M d 21402.
b Pergamon Press, Headington Hill Hall, O x -
ford O X 3 0 B W , England. 4 p.a.
549
c 50-60 p. 6 art. (6-12 p.): Application of
computers in all aspects of higher education.
111. Graphs and tables.
ISSN: 0360-1315
C O N T E M P O R A R Y CRISES. Crime, L a w , Social Policy
[Contemp. Crises] (Jan. 1977- )
a Ed.: W . S. Chambliss, Department of Sociology,
University of Delaware, Newark, D . E . 19711.
b Elsevier Scientific Publishing C o m p a n y , P . O .
Box 211, Amsterdam, Netherlands. 4 p.a.
c 126 p. 7 art. (10-20 p.): International and
multidisciplinary studies of contemporary pol-
itical, economic and social crises, criminology.
Critical reviews (3-10 p.).
C U L T U R E , M E D I C I N E A N D P S Y C H I A T R Y . A n Inter-
national Journal of Comparative Cross-Cultural
Research [Cult. Med. Psychiatry] (Apr. 1977- )
a Ed.: A . Kleinman, Division of Social and Cross-
Cultural Psychiatry, Department of Psychiatry
andBehavioral Sciences, University of Washing-
b D . Reidel Publishing Company, P . O . Box 17,
Dordrecht, Netherlands. 4 p.a.
c 100 p. 5 art. (20-25 p.): Medical and psychiatric
anthropology, cross-cultural psychiatry, cross-
societal epidemiology. Critical reviews. Abstracts.
Graphs. Title index.
EDUCATIONAL GERONTOLOGY, A n International
Quarterly [Educ. Gerontol.] (Jan. 1976- )
a Adult Education Program, Department of
Secondary, Post Secondary Education, Virginia
Commonwealth University, Richmond, Va.
b Hemisphere Publishing Corporation, 1025 Ver-
mont Avenue, N . W . Washington, D . C . 20005.
4 p.a.
c 112 p. 8-9 art. (10-12 p.): Adult education and
gerontology. Inf. (1 p.). Bibliogr. (2 p.). Critical
reviews (3 p.). Abstracts. Table. Subject index.
N . B . Art. in various languages.
ENVIRONMENTAL PSYCHOLOGY A N D NONVERBAL
B E H A V I O R [Environm. Psychol, nonverbal Behav]
1976- )
a E d . : R . M . Lee, Department of Psychology,
Trinity College, Hartford, C o n n . 06106.
b H u m a n Sciences Press, 72 Fifth Avenue, N e w
York, N . Y . 10011. 2 p.a.
 550
c 64 p. 5 art. (10-12 p.): Environmental and non-
verbal influences on human social behavior.
ISSN: 0361-3496
ETHNICITY. A n Interdisciplinary Journal of the
Study of Ethnic Relations [Ethnicity] (1974- )
a Ed.: A . M . Greeley, Center for the Study of I N T E R N A T I O N A L STUDIES N O T E S [Int. Stud. Notes]
American Pluralism. National Opinion R e -
search Center, 6030 South Ellis Avenue, Chi- a Ed.: S. H . Harbold, International Studies
cago, 111. 60637.
b Academic Press, 111 Fifth Avenue, N e w York,
N . Y . 10003. 4 p.a.
c 100 p. 4-5 art. (15-20 p.): Ethnic diversity, c 40-60 p. 5-8 art. (4-16 p.): International
interactions between the various groups within a
society, acculturation, integration.
INTERNATIONAL JOURNAL OF GENERAL SYSTEMS. A
Comprehensive Periodical Devoted to General
Systems Methodology, Applications and Edu-
cation [Int. J. gen. Systems] (1974- )
a Ed.: G . J. Klir, School of Advanced Technology,
State University of N e w York at Bingharton.
b Gordon and Breach Science Publishers,
41/42 William IV Street, London W C 2,
England. 4 p.a.
c 64 p. 4 art. (8 p.): Cybernetics, general theory
of systems. Bibliogr. (5 p.). Critical reviews
(10 p.). Abstracts (10 p.). Table. Title index.
Subject index. Author index.
ISSN: 0308-1079
INTERNATIONAL JOURNAL OF THE SOCIOLOGY OF
L A N G U A G E [Int. J. Sociol. Lang.] (1974- )
a Ed.: J. A . Fishman, c/o Ferkauf Graduate
School, Yeshiva University, 55 Fifth Avenue,
N e w York, N . Y . 10003.
b Mouton, P . O . Box 482, The Hague 2076,
Netherlands. 4 p.a.
c 115-170 p. 8-10 art. (5-25 p.): Each issue is
devoted to a particular subject relating to the
sociology of language: language and education in
the Third World, social dialectology... Review art.
Bibliogr.
N . B . Contents identical to the contents of
some issues of LINGUISTICS.
I N T E R N A T I O N A L SECURITY. Program for Science and
International Affairs [Int. Secur.] (1976- )
a Program for Science and International Affairs,
9 Divinity Avenue, Harvard University, C a m -
bridge, Mass. 02138.
#
b Id. 4 p.a.
c 175 p. 8-10 art. (15-20 p.): International
security: arms control, disarmament, nuclear
proliferation, terrorism . . . Critical reviews (20 p.).
Graphs. Table.
(1974- )
Association, U C I S , University of Pittsburgh,
Pa 15260.
b Id. 4 p.a.
relations. Research notes (4-16 p.). Inf.
JOURNAL OF COMMUNITY HEALTH [J. Community
Health] (Fall 1975- )
a Ed.: R . L . Kane, Department of Family and
Community Medicine, University of Utah
Medical Center, 50 North Medical Drive, Salt
Lake City, Utah 84132.
b H u m a n Sciences Press, 72 Fifth Avenue, N e w
York, N . Y . 10011. 4 p.a.
c 70-100 p. 5-6 art. (8-12 p.): Medical but
also social and political aspects of community
health. Critical reviews (2 p.). Title and author
index.
ISSN: 0094-5145
J O U R N A L O F FAMILY HISTORY. Studies in Family,
Kinship and Demography [/. Family Hist.]
(Sept. 1976- )
a National Council on Family Relations,
1219 University Avenue Southeast, Minnea-
polis, Minn. 55414. Ed.: T . Hareven.
b Id. 4 p.a.
c 100 p. 3 art. (25-40 p.): Family History.
J O U R N A L O F H O M O S E X U A L I T Y [/. Homosexuality]
(Fall 1974- )
a Ed.: C . Silverstein. Institute for H u m a n Ident-
ity, 490 West End Avenue, N e w York,
N . Y . 10024.
b Haworth Press, 149 Fifth Avenue, N e w York,
N . Y . 10010. 4 p.a.
c 100 p. 7-8 art. (15 p.): Homosexuality and
gender identity from various disciplines (psy-
chology, sociology, psychiatry, history, law). Crit-
ical reviews (7 p.). Court cases (4 p.). Annotated
bibliogr. (10 p.). Author index and subject index.
ISSN: 0091-836-9
 Addition No. 2 to the World List
of Social Science Periodicals
JOURNAL OF REPRINTS OF DOCUMENTS AFFECTING
W O M E N [/. Reprints Doc. Women] (Jul. 1976- )
a Today Publications and News Service, National
Press Building, Washington, D . C . 20045. Ed.:
M . Barrer,
b Id. 4 p.a.
c 500 p. 20 doc. (1-50 p.): History, international
agreements, public law, regulations, litigation.
Abstracts (10 p.). Table. Dictionary index.
ISSN: 0362-062X
JOURNAL OF URBAN HISTORY [J. urb. His t.] (1974-
a Ed.: R . A . Mohl, Department of History, Flo-
rida Atlantic University, Boca Raton, Fla 33432.
b Sage Publications Ltd., St George's House,
44 Hatton Garden, London E C 1 N 8 E R . 4 p.a.
c 125-130 p. 4-5 art. (25-30 p.): Urban history:
social mobility, urban development... R e -
views essays. Inf. and notes (2 p.). Critical reviews
(2 p.).
ISSN: 0096-1442
LEGISLATIVE STUDIES QUARTERLY [Legisl.
Quart] (Feb. 1976- )
a Comparative Legislative Research Center,
304 Schaeffer Hall, the University of Iowa,
Iowa 52242.
b Id. 4 p.a.
c 144 p. 5-6 art. (20-25 p.): Legislative studies:
legislatures, members of parliament, represen-
tative institutions, executive-legislative relations.
Inf. (20 p.). Critical reviews (20 p.). Abstracts.
Graphs. 111.
LEISURE SCIENCES. A n Interdisciplinary Journal
[Leisure Sei.] (Feb. 1977- )
a Ed.: C . S. Van Doren, R . J. Burdge.
b Crane, Russak and Co., Inc., 347 Madison
Avenue, N e w York, N . Y . 10017. 4 p.a.
c 100 p. 5-6 art. (11-14 p.): Leisure studies:
sociological, geographical, psychological. Re-
search notes (5 p.). Inf. (3 p.). Critical reviews
(1-2 p.). Graphs (2 p.). 111. (2 p.). Table.
M A S S E M E R G E N C I E S . A n International Journal of
Theory, Planning and Practice [Mass Emerg.]
(1976- )
a Ed.: J. Nehnevajsa, University Center for
Urban Research, University of Pittsburgh.
E . Quarantelli, Disaster Research Center, Ohio
State University.
551
b Elsevier Scientific Publishing Company, P . O .
Box 211, Amsterdam, Netherlands. 4 p.a.
c 90-110 p. 8-10 art. (5-15 p.): Disasters: Plan-
ning and organization of rescue, detection and
forecasting, mass response . . . Graphs. Bibliogr.
M I D A M E R I C A N R E V I E W O F S O C I O L O G Y [Mid Amer. R.
SocioL] (1976- )
a Ed.: C . Flynn, Department of Sociology, Uni-
versity of Kansas, Lawrence, Kans. 66045.
b Id. 2 p.a.
) c 70-80 p. 4-5 art. (10-15 p.): Sociology.
POLICY ANALYSIS [Policy Anal] (1975- )
a Ed.: A . J. Meltsner, Graduate School of Public
Policy, University of California, 2607 Hearst
Avenue, Berkeley, Cal. 94720.
b University of California Press, Berkeley, Cal.
94720. 4 p.a.
c 200-220 p. 4-5 art. (10-25 p.): Government
policy.
P S Y C H O C U L T U R A L (THE) R E V I E W . Interpretations in
Stud.
the Psychology of Art, Literature and Society
[Psychocuit. R.] (Jan. 1977- )
a Ed.: R . Huss.
b Redgrave Publishing Company, a Division of
Docent Corporation, 430 Manville Road, Plea-
santville, N . Y . 10570. 4 p.a.
c 128 p. 6-7 art. (15 p.): Psychological and
psychoanalytical studies of the arts, literature
and culture. Critical studies (5 p.). Title index and
author index.
PSYCHOLOGY OF W O M E N QUARTERLY [Psychol.
Women Quart.] (Fall 1976- )
a Ed.: G . Babladelis, Department of Psychology,
California State University, Hayward, Cal.
94542.
b H u m a n Sciences Press, 72 Fifth Avenue, N e w
York, N . Y .10011. 4 p.a.
c 96 p. 7-8 art. (10-15 p.): W o m e n psychology:
psychobiological factors, behavior, role, career,
education, therapeutic processes and sexuality.
Critical reviews (10 p.). Abstracts (3 p.). Film
reviews (3 p.). Author index.
ISSN: 0361-6843
Q U A R T E R L Y R E V I E W O F FILM STUDIES [Quart. R.
Film Stud.] (1976- )
a Ed.: R . Gottesman, University of Southern
California, c/o Redgrave Publishing Company,
 552

v
=s
a Division of Docent Corporation, 430 M a n - University, 493 College Street, N e w Haven,
ville Road, Pleasantville, N . Y . 10570. Conn. 06520.
b Id. 4 p.a. b Redgrave Publishing Company, 430 Manville
c 128 p. 8-10 art. (5-15 p.): Interdisciplinary Road, Pleasantville, N . Y . 10570. 4 p.a.
studies onfilm.Critical reviews (10 p.). Dic- c 128 p. 4 art. (15 p.): Interdisciplinary studies on
tionary index. past and contemporary Italian culture. Critical
reviews (7 p.). Title index and author index.
R E V I E W (THE) O F E D U C A T I O N [R. Educ] (1975- )
a Ed.: H . J. Perkinson, N e w York University,
School of Education, 737 East Building, Wash- OIG
ington Square, N e w York, N . Y . 10003. Intergovernmental Organizations
b Redgrave Publishing Company, a division of
Docent Corporation, 430 Manville Road, Plea- POPULI. Journal of the United Nations Fund for
santville, N . Y . 10570. 6 p.a. Population Activities [Populi] (1974- )
c 80-100 p. 10-12 critical reviews and review a Ed.: A . Marshall, United Nations Fund for
art. (5-10 p.): Sciences of education. Dic- Population Activities, 485 Lexington Avenue,
tionary index. R o o m L X - 2 1 0 2 , N e w York, N . Y . 10017.
b Unipub, P . O . Box 433, Murray Hill Station,
Y A L E ITALIAN STUDIES [YaleItal. Stud.] (Jan. 1977- N e w York, N . Y . 10016. 4 p.a.
) c 48 p. 5-6 art. (6-8 p.): Population and devel-
a Ed.: J. Freccero, Department of Italian, Yale opment. Critical reviews (3 p.).
 Approaching international conferences1

1977

Late 1977 Gerontological Society: Annual Scientific Meeting

Salt Lake City E. Kaskowitz, Gerontological Society, One DuPont Circle, Washington,
DC 20036 (United States)

19-23 September Paris International Conference o n Data Processing

Convention informatique, 6, Place de Valois, 75001 Paris (France)
19-24 September Pavia International Society for the Study of Behavioral Development: Fourth
Biennial Congress (Theme: Biosocial Aspects of DevelopmentAn
Interdisciplinary Approach)
ISSBD, Professor Marcello Cesa-Bianci, Via Francesco Sforza 23,
20100 Milano (Italy)
22-26 September World Energy Conference: Tenth World Energy Conference
Istanbul World Energy Conference, Mr Ruttley, Secretary-General, 5, Bury Street,
London SW1 6AB (United Kingdom)
22 September to Sofia Inter-Parliamentary Union: Sixty-Fourth Conference
3 October Inter-Parliamentary Union, Place du Petit Saconnex, 1211 Geneva 28
(Switzerland)

October Singapore International Council for Scientific Management; Asian Association of

Management Organizations: Sixth Triennial Conference
Singapore Institute of Management, Thong Teck Building, Singapore 9
October Ireland International Society of Economic Sciences: Meeting
The Agricultural Institute, Klnsealy Research Station, Malahide Road,
Dublin (Ireland)
October Chicago Project Management Institute: Annual Seminar (Theme: Realities in
project management)
Project Management Institute, J.R. Snyder, Box 43, Drexel Hill,
PA 19026 (United States)
2-4 October Society for International Development: Alternatives to Growth '77'
The Woodlands, Alternatives to Growth, c/o Society for International Development, 1346
Texas Connecticut Avenue N.W., Room 1131, Washington, DC 20036 (United
States)
12-21 October Systems Safety Society: Third International Conference on Security
Washington systems in a world of diminishing resources
Systems Safety Society, P.O. Box 165, Washington DC 20044 (United
States)
24-29 October Centre Africain de Formation et de Recherches Administratives pour le
Dar es Salaam Dveloppement : Sminaire de Recherche sur le Dveloppement Urbain-
rural Intgr (bilingual)
CAFRAD, P.O. Box 310, Tangier (Morocco)
30 October to Pointe-- United T o w n s Organization: Ninth Congress (Theme: Future of munici-
2 November Pitre palities-democracy-decolonization-development)
United Towns Organization, 13 Rue Racine, 75006 Paris (France)
31 October to Geneva European Social Development Programme; European Centre for Social
3 November Welfare Training and Research, Vienna: Sixth Planning Conference on
the European Social Development Programme
United Nations, Division of Social Affairs, 1211 Geneva (Switzerland)

I. N o further details concerning these meetings can be obtained through this Journal.

Int. Soc. Sei. J., Vol. X X I X , N o . 3, 1977

 m
554

November Paris International Association for Bridge and Structural Engineering; Joint
Committee on Tall Buildings: Meeting (Theme: 2001 Urban space for
life and work)
1ABSE, A. Golay, ETH-Hnggenberg, 8093 Zrich (Switzerland)
7-11 November Asian Federation for Mentally Retarded: Third Asian Conference on
Bangalore Mental Retardation
Asian Federation for the Mentally Retarded, 2 Krishna Menon Marg
New Delhi 110001 (India)
21-26 November Centre africain de formation et de recherches administratives pour le
Tangier dveloppement : Meeting on the implications of the new international
economic order (trilingual)
CAFRAD, P.O. Box 310, Tangier (Morocco)
26-29 November Cairo International Federation of Automatic Control: Second Conference on
Systems Approaches for Development
International Federation of Automatic Control, c\o EKONO, attn.:
S. Aarnio, P.O. Box 27, SF-00310 Helsinki 13 (Finland)
29 November to American Anthropological Association: Annual Meeting
4 December Houston AAA, L. D. Horn, 1703 New Hampshire Ave, N. W., Washington,
Texas DC 20009 (United States)

December International Association of Survey Statisticians: Third Meeting

International Statistical Institute, 428, Prinses Beatrixlaan Vo
near The Hague (Netherlands)
11-16 December Mexico International Peace Research Association: Seventh General Conference
IPRA, P.O. Box 70, 33101 Tampere 10 (Finland)
19-21 December Freetown Christian Peace Conference: African Christians Involvement in Liber-
Sierra Leone ation, Justice and Peace
CPC, Jungmannova 9, Prague 1 (Czechoslovakia)
27-29 December Econometric Society: Conference
United States Econometric Society, c/o Department of Economics, Northwestern
University, Evanston, IL 6020I (United States)

1978

India International Congress of Anthropological and Ethnological Sciences

Mario D. Zamora, Department of Anthropology, College of William and
Mary, Williamsburg, VA 23185 (United States)
Rome International Society of Criminology: Eighth World Congress
International Society of Criminology, J. E. H. Williams, Secreta
General, 4 Rue de Mondovi, 75001 Paris (France)

13-15 April Atlanta Population Association of America: Meeting

PAA, P.O. Box 14182 Banjamin Franklin Station, Washington, DC 20044
(United States)

June Zurich Twenty-Fifth International Congress on the Prevention and Treatment of

Alcoholism
Zrich Tourist Office, Congress Department, Bahnhofbrcke 1, 8023
Zrich (Switzerland)
 Approaching international conferences 555

July Montreal International Association of Youth Magistrates: Tenth Congress

(Theme: T h e magistrate and the pressions of the environment on youth
and family)
International Association of Youth Magistrates, Secrtariat Gnral,
Tribunal pour les Enfants de Paris, Palais de Justice, 75055 Paris (France)
30 July to Munich International Association of Applied Psychology: Nineteenth Inter-
5 August national Congress
IAAP, 47 Rue Csar Franck, Lige (Belgium)

14-26 August Uppsala International Sociological Association: Ninth World Congress

ISA, P.O. Box 719, Station A, Montreal (Canada)
19-26 August Melbourne International Association for Child Psychiatry and Allied Professions:
Ninth International Congress (Theme: Children and parents in a chang-
ing world)
Peter B. Neubauer, Secretary-General International Association for Child
Psychiatry and Allied Professions, 59 East 73rd Street, New York,
N.Y. 10021 (United States)
20-24 August Tokyo International Association of Gerontology: Eleventh International
Congress
International Association of Gerontology, Dr M . Murakami, Tokyo
Metropolotan Geriatric Hospital, 35-2 Sakaecho, Itabashiku, Tokyo
(Japan)
21-26 August Montreal International Association of Applied Linguistics: Fifth International
Congress
Secretariat of the AILA Congress 1978, co Jacques D. Giraud, University
of Montreal, Box 6128, Station 'A', Montreal (Canada)
27 August to Dusseldorf International Federation of Societies of Philosophies: Sixteenth World
2 September Congress
Professor Andr Mercier, International Federation of Societies of Philos-
ophies, Institut des Sciences Exactes, 6, Sidlerstrasse, 3012 Bern
(Switzerland)

3-8 September Warsaw International Council o n Alcohol and Addictions: Thirty-second Inter-
national Congress o n Alcoholism and Drug Dependence
ICAA, A. Tongue, Case postale 140,1001 Lausanne (Switzerland)
24-28 September Alcohol and Drug Problems Association of North America: Meeting
United States ADPANA, 1101 Fifteenth Street, N.W., Washington, DC20006 (United
States)

1979

Philadelphia Population Association of America: Meeting

PAA, P.O. Box 14182, Benjamin Franklin Station, Washington,
DC 20044 (United States)
August Novosibirsk A c a d e m y of Sciences of the U . S . S . R . : Fourteenth Pacific Science
Congress
Professor A. P. Kapitsa, President of the Far East Research Centre,
Academy of Sciences of the U.S.S.R., 50 Leninskaya Street Vladivostock
(U.S.S.R.)
 Materials from the United Nations system:
an annotated selection1
Sales publications may be bought at the depository bookstores of the United Nations and Specialized
Agencies. Materials, publications and documents may be consulted at the United Nations information
centres or at the headquarters'' libraries or documentation centres of each organization mentioned.
Population, health, food
and agriculture, environment
Population
Concise Report on Monitoring of Population Trends.
N o v e m b e r 1976. 49 p . ( U N / E / C N . 9 / 3 2 3 . )
This document deals with recent population trends.
After reviewing a number of major aspects of world
population trends during the period from 1950 to
1975, the paper deals with size and growth of popu-
lations; their mortality, fertility, international m i -
gration components; urban-rural distribution and
redistribution; demographic structure and character-
istics and s o m e major social and economic concomi-
tants of population trends, specifically education,
labour-force dependency and food supply.
Concise Report on Monitoring of Population Policies.
N o v e m b e r 1976. 41 p . ( U N / E / C N . 9 / 3 2 4 + 2 an-
nexes.)
This report deals successively with: (a) government
perceptions of and policies relating to the rate of
natural increase of the population; (b) mortality;
(c) fertility; (d) spatial distribution of the population
and internal migration; (e) international migration;
(f) institutional arrangements for the formulation
and integration of population policies in the develop-
ment plans. T h e study covers the period between
the close of the World Population Conference in
Bucharest (19-30 August 1974) and the Third Inquiry
a m o n g governments on population and development
(1 July 1976). It takes into account levels of develop-
ment of countries, both developed and developing,
and their geographical distribution (in terms of m e m -
bership in the five United Nations regional c o m -
missions).
1. A s a general rule, no mention is made of publications
and documents which are issued more or less
automatically: regular administrative reports,
minutes of meetings, etc. W h e n the context of
the text is self-evident, n o description has been
Int. Soc. Sei. J., Vol. X X I X , N o . 3, 1977
Health
Family Formation Patterns and Health. 1976. 562 p .
50 Swiss francs. W H O , Geneva. A n inter-
national collaborative study in India, Iran,
Lebanon, Philippines and Turkey.
These collaborative studies aim at elucidating the
relationship between family health and factors affect-
ing fertility formation, and begin with a review of the
evidence and research design for the studies. T h e
reports from the countries deal with the following
topics: study areas and population characteristics,
family formation and pregnancy outcome, childhood
mortality, child development, maternal health, child
loss and family formation, family formation and
birth control, behaviour and attitudes.
Social and Health Aspects of Sexually Transmitted
Diseases. Principles of Control Measures. 1976.
56 p . 8 Swiss francs. W H O . (Public Health
Papers N o . 65.)
T h e material in the book constitutes a summary of
the problems and control of sexually transmitted
diseases for public health, health education and social
workers and provides useful background information
for others interested in the subject.
Legislative Action to Combat Smoking Around the
World: A Survey of Existing Legislation. 1976;
Vol. 2 7 , N o . 3, Offprint from International
Digest of Health Legislation. 28 p . 6 Swiss
francp. W H O .
The present study is an attempt to analyse the legis-
lative measures that have been adopted by both de-
veloped and developing countries, such as warning
notices o n cigarette packages, restrictions o n adver-
tising, and even bans on smoking in various establish-
provided. The following conventional abbrevi-
ations have been used: Bl.: contains a par-
ticularly interesting bibliography. St.: specially
important or rare statistics.
 Materials from the United Nations system:
an annotated selection
ments, means of transport, etc. T h e survey also
covers the setting up of national bodies to co-ordinate
anti-smoking programmes. Attention is paid to the
very genuine obstacles to the introduction and enforce-
ment of effective legislation in this area.
Food, nutrition, agriculture
Social and Imtitutional Reforms as a Means of In-
creasing Domestic Food Production and Dis-
tributing it Equitably among the Population. The planning and programming of agricultural research.
Joint report of the Secretariats of the United
Nations, the International Labour Office, the
Food and Agriculture Organization and the
World Bank. October 1976. 32 p . ( U N / E /
CN.5/537.)
Thefirstpart of the report deals with the lag in food
production in a number of developing countries and difficulties involved in the use of these methods.
ways in which the problem may be solved. Land
tenure reforms, institutional changes and the creation
of rural participatory systems as prerequisites for
expanding production are discussed, and successful
marketing reforms already attempted are described,
as is the need for extra-market distribution channels.
Nutrition in Preventive Medicine, by G . H . Beaton The Interparliamentary Union, jointly with the
and J. M . Bengoa, 1976. 590 p . 83 Swiss
francs. W H O . (Monograph Series N o . 62.)
U p to the present there has been no comprehensive
treatment of malnutrition and preventive medicine,
and W H O therefore undertook the preparation of
such a work, with the help of twenty-six specially
invited contributors and a similar number of expert
reviewers. Thefirstpart of the monograph consists of
nine chapters on the major deficiency syndromes,
their treatment and prevention. T h e four following
chapters deal with the epidemiological aspects of
malnutrition. Part three covers approaches to control: what happens to pollutants and h o w they affect
the family unit in health programmes, surveillance of
the population at risk, nutrition education, food for- a programme of pollution control and draws up an
tification, and the planning and organization of a
national food and nutrition policy. T w o chapters on
food production and food marketing are contributed
by F A O . With six annexes and an extensive index.
Microbiological Aspects of Food Hygiene. 1976. 103 p.
9 Swiss francs. ( W H O Technical Report
Series N o . 598.) Report of a W H O Expert
Committee with the participation of F A O .
The committee reviewed the wholefieldof food-borne
microbiological hazards, considered n e w develop-
ments that have occurred since previous W H O re-
views of food hygiene and food-borne disease in 1967
and 1973, considered in previous reports, and m a d e
important recommendations for improvements in
food hygiene.
557
Training for Agricultural and Rural Development .1976.
144 p. ( F A O Development Series N o . 2.)
(FAo/iLo/Unesco.)
[Bl.] This publication which resulted from the F A O /
ILO/Unesco World Conference on Agricultural E d u -
cation and Training held in 1970, features only a
cross-section of contemporary experiences and view-
points in this important area of work. It contains
seventeen selected papers and aims at stimulating the
generation of trained manpower.
1975. 122 p . by I. Arnon. F A O , R o m e . With
11 illustrations and 4 tables.
[St. Bl.] O n e of the objectives of this document has
been a survey of the proposed methods for evaluating
research projects (mainly in industrial research). It
also attempts to provide insight into the problems and
Environment
An Environmental Sanitation Plan for the Mediter-
ranean Seaboard: Pollution and Human Health,
by J. Brisou, Geneva. 1976. 96 p. 10 Swiss
francs. W H O , Geneva. (Public Health Papers
N o . 62.)
Italian parliamentary authorities and the United
Nations Environment Programme ( U N E P ) , organized
a conference of coastal States on control of pollution
in the Mediterranean, which was held in R o m e from
29 March to 3 April 1974. Professor J. Brisou, w h o
was one of the experts commissioned by U N E P to
prepare the background documentation for the confer-
ence, drafted a report on the health implications of
pollution in the Mediterranean. After reviewing the
main sources of pollution and describing the present
situation in the Mediterranean, the author explains
h u m a n health. H e concludes his study by proposing
inventory of the measures to be put into effect for the
sanitary rehabilitation of the Mediterranean.
Air Quality in Selected Urban Areas 1973-1974. W H O ,
Geneva. 1976. 65 p . 15 Swiss francs. ( W H O
Offset Publication N o . 30.) Published under
the joint sponsorship of U N E P and W H O .
The information was collected at three sampling sites
in one major city in each of fourteen participating
countries, the sites being representative of an indus-
trial area, a commercial area, and a residential area.
The data are given in an annex to a brief introductory
report, with data showing a particular pollutant in a
particular city, and for each year the number of
samples analysed and the m i n i m u m and m a x i m u m
concentrations of pollutant.
 558

= ^

A Comprehensive Plan for the Global Investigation Statistics on Science and Technology in Latin America.
of Pollution in the Marine Environment and Experience with Unesco Pilot Projects 1972-
Baseline Study Guidelines. 1976. 4 2 p . (In- 1974, by Schiller Thbaud. 1976. 76 pages.
tergovernmental Ocanographie Commission 10 F . (Unesco Statistical Reports and Studies
Technical Series N o . 14.) Unesco. N o . 20.) Centre National de la Recherche
This programme ( G I P M E ) provides an international Scientifique, Institut de Prospective et de Poli-
framework within which national and regional pro- tique de la Science, France.
grammes on various aspects of marine pollution m a y
be co-ordinated to contribute to an understanding of
global pollution problems. T h e study analyses both Economie development
the scientific and the implementation frameworks and
draws up baseline study guidelines. The Future of the World Economy. 1976. 350 p .
Preliminary.
Indicators of the Quality of Urban Development. 1977. [St.] This report was prepared by a research team led
47 p . $ 4 . ( U N / S T / E S A / 5 6 - E . 7 7 . I V . 4 . ) by A n n e P . Carter, Wassily Leontief and Peter Petri.
Report of the Meeting of the Ad Hoc Group of A study o n the impact of prospective economic issues
Experts held at United Nations Headquarters from 8 and policies on the International Development Strat-
to 12 December 1975. egy. With seventy-six statistical tables. T h e basis for
the report is a study on the environmental aspects of
the future world e c o n o m y . It includes as a principal
feature a set of alternative projections of the d e m o -
Economics graphic, economic and environmental status of the
world in bench-mark years 1980, 1990 and 2000.
Statistics
Economic and Social Survey of Asia and the Pacific
Demographic Yearbook 1975/Annuaire Dmographi- 1975. September 1976. 174 p . $10 ( U N / S T /
que. 1976. 1, 118 p . Clothbound: $ 42; paper- ESCAP/2-E.76.II.F.1.)
bound: $ 3 4 . ( U N / S T / E S A / S T A T / S E R . R / 4 - E / F . 7 6 .
Part O n e of this survey contains a review of the
xm. 1.) current economic and social situation in the region.
Part T w o is devoted to an in-depth study of rural
World Statistics in Brief. August 1976. 241 p . $ 3.95. development, particularly in relation to the small
(UN/ST/ESA/STAT/SER.V/1-E.76.XVII.6.) farmer and institutional reform. M a n y countries of
the region are placing increasing emphasis o n pro-
Statistical Yearbook for Asia and the Pacific 1975/ grammes for rural development and the Survey exam-
Annuaire Statistique pour l'Asie et le Pacifique.ines the role of the small family farm in rural and
N o v e m b e r 1976. 486 p . $ 2 5 . ( U N / E / C N . 1 1 / general economic development in the areas of the
1243-E/F.76.II.F.17.) Economic and Social Commission for Asia and the
Pacific and m a k e s suggestions for a small farmer
Statistics on Narcotic Drugs for 1975 Furnished by development strategy.
Governments in Accordance with the Inter-
national Treaties and Maximum Levels of
Opium Stocks. January 1977. 99 p . $ 7 . Financing of Public Enterprises in Developing
( U N / E / I N C B / 3 5 - E . 7 6 . X I . 7 . ) International Nar- Countries: Co-ordination, Forms and Sources.
cotics Control Board, Geneva. D e c e m b e r 1976. 73 p . $5. ( U N / S T / E S A / S E R . E /
7-E.77.n.H2.) With 11 statistical tables.
World Health Statistics Annual, Volume III, 1973- [St.] This volume contains two monographs. T h e
1976: Health Personnel and Hospital Establish- first, prepared by Reginald H . Green as a consultant
ments. 1976. 340 p . 48 Swiss francs. W H O , to the United Nations, is 'Public Enterprise Finance
Geneva. Bilingual: English/French. and National Development Goals: S o m e Aspects of
T h e special subject presented in this edition is o n Co-ordination, Articulation and Efficiency'. T h e se-
the distribution of personnel in selected health oc- cond monograph, 'Capital Structure of Public Enter-
cupations by sex and age (or by sex only) in 1960 prises in Developing Countries', was prepared by the
and 1970 or for the latest year available. United Nations Secretariat. The monographs identify
the major issues involved in the financing of public
Year Book of Labour Statistics, 1976. Thirty-sixth enterprises under different circumstances and discuss
issue. 968 p . 95 Swiss francs. Hard cover. the principal questions which have to be resolved in
Trilingual: English/French/Spanish. Inter- arriving at effective solutions to various problems of
national Labour Office. financing public enterprises.
 Materials from the United Nations system:
an annotated selection
International Finance, Depressed Regions and Needed
Progress. September 1976. 27 p . $2.50 ( U N / S T /
ESA/48-E.76.n.A.8.) Views and r e c o m m e n -
dations of the United Nations Committee for
Development Planning.
T h e Committee formulated their views and rec-
ommendations on two issues: (a) crucial aspects of
the flow offinancialresources to developing countries
for economic development and social progress; and
(b) problems and policies relating to depressed regions
of the worldthat is, groups of countries facing
stubborn poverty and underdevelopment.
The Tropics and Economic Development. A Pro-
vocative Inquiry into the Poverty of Nations,
by A n d r e w M . Kamarcek. A World B a n k
Publication. 1976. 113 p . Washington. With
a foreword by Paul Streeten. With 9 m a p s
and a bibliography.
Industrialization
Planning Techniques for a Better Future. 1976. 91 p .
17.50 Swiss francs. International Labour Of-
fice, Geneva. A World E m p l o y m e n t Study,
by G r a h a m Pyatt and Erik Thorbecke.
Foreword by Louis Emmerij. A summary of
a research project o n planning for growth,
redistribution and employment.
In the developing countries, the past and present
concentration of development planning and policies
in the modern sector has not been accompanied by
increased productivity and higher incomes in the tra-
ditional rural and the older urban sectors; nor have
the fruits of the exceptional economic growth that has
occurred been m a d e available to the majority of the
people. In an attempt to correct this deficiency, the
authors adopt a systematic and unified approach to
development policies that bring together both growth
and redistribution elements in a single framework.
Management and Productivity: an International Direc- by the committee. The three annexes contain the
tory of Institutions and Information Sources. main conclusions and recommendations of the Sem-
1976. 243 p . 25 Swiss francs. Trilingual:
English/French/Spanish. I L O , Geneva. ( M a n -
agement Development Series N o . 13.)
A directory listing over 1,600 institutions and
800 information sources in the m a n a g e m e n t develop-
ment and productivity fields from 125 countries.
Institutions from most developing countries are in-
cluded, in addition to those of North America and
Eastern and Western Europe.
Housing
Housing Policy Guidelines for Developing Countries.
N o v e m b e r 1976. 124 p . $ 8 . ( U N / S T / E S A / 5 0 -
E.76.W.11.)
[St.] T h e report is divided into two parts. T h e first
part views housing within its intersectoral frameworks
559
formulating guidelines which communicate the econ-
omic as well as the social importance of housing
within a national development context. T h e second
part focuses on the intersectoral aspects of considering
housing priorities and evaluating alternative ways of
allocating and using scarce housing resources. With
five statistical tables.
Natural resources, energy
Water1
Report of the ESCAP Regional Preparatory Meeting
for the UN Water Conference. (Bangkok,
27 July-2 August 1976.) October 1976. 55 p .
(UN/E/CONF.70/4.)
T h e Executive Secretary of the Economic and Social
Commission for Asia and the Pacific pointed out the
difficulties and challenges facing the countries and
cited the rapidly increasing water d e m a n d for agri-
culture, industry and rural dwellers, only about
10 per cent of w h o m had reasonably safe and assured
water supplies. Seventeen country reports were pre-
sented at the meeting, a report o n the water situation
in the L o w e r M e k o n g basin andfiveconference r o o m
papers o n national reports.
Economic Commission for Europe. Regional Report.
November 1976. 70 p . + 3 Annexes, ( U N /
E / C O N F . 7 0 / 6 . ) With 12 statistical tables.
Prepared under the auspices of the E C E
Committee on Water Problems, Geneva.
[St.] The committee held its eighth session in Geneva
from 27 September to 1 October 1976. The report,
which was meant to be the main contribution of the
E C E to the United Nations Water Conference,
contains two main parts and three annexes. Part I on
policy options in water use and development in the
E C E region is an introduction to Part II which
contains the recommendations for action prepared
inar on Long-Term Planning of Water Management
held in Bulgaria in M a y 1976, and two studies dealing
respectively with the principles and methods of
economic incentives in water supply and waste water
disposal systems, and with rational methods of flood
control planning inriverbasin development.
Economic Commission for Africa. Regional Report.
January 1977. 85 p . ( U N / E / C O N F . 7 0 / 7 . ) With
22 statistical annexes.
[St.] This report deals with the principal problems
in the field of the development of water resources
1. The United Nations Water Conference was held
in M a r del Plata, Argentina, from 14 to
25 March 1977. A selection of documents pre-
sented to the conference is described herewith.
 560
in Africa as adopted at an African regional meeting
on water resources, held at Addis Abada in
September 1976, in preparation for the United Nations
Water Conference. The regional report synthetizes the
data, information, ideas, suggestions and recommen-
dations m a d e by thirty-four countries in Africa in
reports specially prepared for the regional meeting. It
is m a d e up of three parts: thefirstis of an introduc-
tory nature, the second deals with principal matters
requiring the attention of scientists and admin-
istrators in thefieldof the development of water
resources, the third, specific action recommendations
with possible lines of implementation at the national
level by the countries concerned, and at the inter-
national level by appropriate international organ-
izations.
Report of the Economic Commission for Western Asia F A O , W H O , with inputs from the United Nations
Regional Preparatory Meeting for the UN Environmental Programme and the World Bank.
Water Conference. January 1977. 33 p. ( U N / E /
CONF.8.) (Baghdad, 11-16 December 1976.)
With 7 statistical tables.
[St.] The report contains a general summary on physi-
cal features and meteorological conditions, assess-
ment of the water situation in the region, potential
and limitations of technology, policy options and
action proposals.
The Water Resources of Latin America. Regional
Report. August 1976. 73 p . ( U N / S T / C E P A L /
CONF.57/L.2.)
This document was prepared by the Economic
Commission for Latin America on the basis of the
eleven national reports received and of the contacts
established with governments by a consultant es-
pecially engaged for the purpose and by the staff of
the commission which has been following the evol-
ution of water management problems in the region
for years. The report studies the supply and uses of
the resources and technology, its promises, potential
and limitations. Policy options are provided.
Water for Agriculture. January 1977. 37 p . ( U N / E /
C O N F . 7 0 / 1 1 . ) With 7 statistical tables and
figure. Prepared by F A O .
The document was reviewed, revised and en-
dorsed by a consultant panel in R o m e from IS
to 17 November 1976. Possibilities for increasing
production, the scale of action, irrigation and drain-
age, h u m a n resources and skills, water supplies for
rural settlement, aquaculture. Proposed action pro-
gramme on water for agriculture.
Technical Co-operation Among Developing Countries
with Regard to Water Resources Development.
January 1977. 16 p . ( U N / E / C O N F . 7 0 / 1 2 . )
This paper contains the report of the Ad Hoc Group
of Experts on Technical Co-operation a m o n g devel-
oping countries in water resources development. It
suggests an improved information base and studies
research, education and training, experts and consult-
ancy services, standardization of services and
equipment.
The Promise of Technology: Potential and Limitations.
N o v e m b e r 1976. 30 p . + 52 p . ( U N / E / C O N F . 7 0 /
C B P / 2 and A d d . )
Prepared by the United Nations Water Conference
secretariat in co-operation with the interested organ-
izations and programmes of the United Nations
system, with the assistance of D r Blair Bower,
consultant, and D r Wdzislaw Kaczmarek. T h e ad-
dendum contains the contributions of the World
Meteorological Organization with inputs from the
United Nations Secretariat, Unesco and I A E A , of
World Catalogue of Very Large Floods. 1976. 424 p.
with tables and maps. 100 F . Unesco (Studies
and Reports in Hydrology N o . 21.) Quadri-
lingual: English/French/Russian/Spanish.
Long-term Planning of Water Management. Ja-
nuary 1977. Vol. I, 99 p . $7. ( U N / E / E C E /
Water/15-E.76.n.E.27.)
Principles and Methods for the Provision of Economic
Incentives in Water Supply and Waste Water
Disposal Systems Including the Fixing of
Charges. January 1977. 25 p. $2. ( U N / E / E C E /
Water 16-E.76.n.E.25.)
Rational Methods of Flood Control Planning in River
Basin Development. January 1977. 71 p . $5.
(uN/E/ECE/Water/17-E.76.n.E.26.)
Non-conventional Water Resources: Some Ad-
vances in their Development, by M e n a h e m
Kantor, Water Commissioner of Israel.
N o v e m b e r 1976. 28 p . ( U N / E / C O N F . 7 0 / A . 2 . )
International River Basin Cooperation: the Lessons
from Experience, by Professor I. K . Fox, and
M r L . Marquand, Westwater Research
Centre, University of British Columbia,
Canada. November 1976. 26 p . ( U N / E /
CONF.70/A.3.)
The Design and Evaluation of Institutional Arrange-
ments for Water Planning and Management,
by Professor Charles W . H o w e , University of
Colorado. November 1976. 56 p . ( U N / E /
CONF.70/A.4.)
 Materials from the United Nations system:
an annotated selection
Water: Resource and Hazard. January 1977. 18 p .
Prepared by the Office of the United Nations
Disaster Relief Co-ordinator ( U N D R O ) .
Energy
Proceedings of the Meeting of the Expert Work-
ing Group on the Use of Solar and Wind
Energy. 1976. 147 p . $9. ( U N / S T / E S C A P / 7 -
E.76.n.F.13.) (Energy Resources Development
Series N o . 16.) Economic and Social C o m -
mission for Asia and the Pacific.
This publication contains the report and documents
of the meeting of the above-mentioned working group
held by E S C A P from 2 to 9 March 1976 as part of the
continuing programme o n the utilization of non-
conventional energy resources. Part O n e contains the
report of the Meeting, Parts 2 , 3 and 4 include
technical documents contributed by the experts on
solar energy, wind energy and integrated systems
utilizing solar and/or wind devices, respectively.
Social questions
Rehabilitation of the disabled
Sport for the Physically Handicapped, by Sir Ludwig
Guttmann. 1976. 53 p . Unesco.
[Bl.] The purpose of this booklet is to help the handi-
capped to develop into productive and well-adjusted
m e m b e r s of the community. Taking an active part in
sporting activities improves the psychological equi-
librium of the handicapped and thus helps to re-
establish contact with the world around. It also
develops mental and ethical attitudes that are essential
for successful social integration and re-integration and
for useful employment.
Prevention of crime
International Review of Criminal Policy. Sep-
tember 1976. 94 p . $7. ( U N / S T / E S A / S E R . M / 3 2 -
E.76.IV.3.)
Issue N o . 32 of the International Review of Criminal
Policy deals with the subject of n e w and special
problems of crimenational and transnational. The
intention is to discuss the change in the patterns
of crime in recent years and to concentrate on the
n e w emerging types of crime such as air piracy, ter-
rorism and kidnapping of public figures. It is hoped
that these discussions will draw attention to the
criminogenic effects of a number of social ills,
a m o n g which drug addiction and alcoholism figure
prominently.
Corrupt Practices, Particularly Illicit Payments,
in International Commercial Transactions:
Concepts and Issues Related to the Formulation
561
of an International Agreement. January 1977.
20 p . ( U N / E / A C . 6 4 / 3 . )
This report examines the concepts and issues related
to the formulation of an international agreement o n
corrupt practices, particularly illicit payments in in-
ternational commercial transactions. Chapter I at-
tempts to elaborate o n the major concepts involved,
such as 'corrupt practices', 'bribery', 'illicit pay-
ments' and 'international commercial transactions',
and to identify the various possible classifications of
such corrupt practices, as well as the parties involved.
Chapter II underscores the need for international
action and discusses the types of actions, both national
and international, that might be embodied in a rel-
evant international agreement. It also discusses the
types of machinery that could be created in the
agreement in order to enforce its provisions and to
ensure the settlement of any disputes relating to its
interpretation or application.
The aged
The Aging in Slums and Uncontrolled Settlements.
January 1977. 48 p . $4. ( U N / S T / E S A / 5 5 - E . 7 7 .
IV.2.) With 11 statistical tables and 1 figure.
[St.] T h e Expert Group meeting which took place at
United Nations Headquarters in M a y 1974 urged
that the question of ageing should be adequately
covered by studies of the Secretariat in the social
field. Subsequently, in conjunction with activities
executed in 1974 and 1975, the Secretariat conducted
a global study to assess the conditions and needs of
the aging in slums and uncontrolled settlements. T h e
report is based on four country studies carried out in
Colombia, Jamaica, H o n g K o n g and Lebanon by
consultants. The report deals with urban population,
the aging population in urban and uncontrolled areas,
status, conditions and needs of the aging in slums and
squatter settlements, policies, programmes and ser-
vices for the aging population in uncontrolled
settlement.
Social policy
Review and Appraisal of the International Development
Strategy. October 1976. 41 p . ( U N / E / C N . 5 /
549.) Popular participation: w o m e n , youth
and children.
T h e report is submitted in four sections. Section I is
an interim review and appraisal of selected national
development strategies designed to promote popular
participation, and describes the efforts of national
governments to incorporate popular participation in
their development programmes. Section II is a prog-
ress report o n the status of w o m e n and reviews the
measures being taken by governments to improve the
status of w o m e n and their integration in the develop-
m e n t process as agents of social and economic change.
 562

Section III is a progress report o n the situation of possibilities for intersectoral co-ordination of training
youth and summarizes the current demographic, e m - activities.
ployment, educational and health situation of youth
The
Social Impact of Housing. Goals, Standards,
and the efforts to increase their participation in
Social Indicators and Popular Participation.
national development. Section IV is a report on basic
February 1977. 93 p . $7. ( U N / E S A / O T C / S E M /
services for children at the mid-point of the Second
77/2-E.77.IV.5.)
United Nations Development Decade.
A n Interregional Seminar o n the Social Aspects of
Housing was organized by the United Nations in co-
Popular Participation and its Practical Implications operation with the Government of D e n m a r k , from 14
for Development. September 1976. 28 p . to 27 September 1975. T h e participants contributed
(UN/E/CN.5/532.) thirty-four country monographs, based on a c o m m o n
This progress report studies the promotion of popular outline, and these offered a consensus on the defi-
participation by governments. T h e areas where pri- nition of housing in the context of government pol-
ority has been assigned are: community development icy and national action, and o n practical consider-
programmes at the local and regional levels; insti- ations that participants felt should be taken into
tutional developments; improving communications account in developing strategies to improve housing
between the people and the government; developing conditions. Discussions were held on the subject of:
methodologies for evaluating the effects of develop- (a) social aspects of housing standards; (b) standards
ment programmes on intended beneficiaries; develop- for community facilities, social amenities and services
ing schemes and materials for training local people in housing projects; (c) social indicators for housing;
and government officials in promoting and sustaining and (d) community participation in the planning and
popular participation in development programmes. implementation of housing programmes. T h e report
The report describes the actions taken by the United contains the seminar recommendations o n each
Nations Development P r o g r a m m e and the Special- subject.
ized Agencies and by the United Nations.
Employment
Review and Appraisal of the International Development
Employment Policy in the Second UN Development
Strategy. The Problems Confronting Youth
Decade. 1976. 44 p . 8 Swiss francs. I L O ,
and the Manner in which these Problems are
Geneva.
Being Treated by the Organs and Executive
This little volume is designed to m a k e available t w o
Bodies of the UN System. October 1976. 44 p .
recent documents recording s o m e of the progress m a d e
(UN/E/CN.5/534.)
in this concerted action by the whole United Nations
The report describes the situation, needs and aspir-
system to generate wider and m o r e productive e m -
ations of youth, including a brief statistical overview
ployment opportunities as an essential element of a
of the world's youth, a discussion of the problems
strategy of development in which economic growth
confronting youth. T h e structure and functioning of
is n o longer regarded as an end in itself but as a
the organs and executive bodies of the United Nations
m e a n s of achieving social objectives. T h e first of
system are also reviewed in this respect. In section II,
these documents is a report on employment policy
a n u m b e r of alternative approaches to co-ordinated
in the Second United Nations Development D e c a d e
planning for youth policies and programmes at the
submitted by the Administrative Committee o n C o -
national level are discussed.
ordination of the United Nations and Specialized
Agencies to the Economic and Social Council. T h e
The Improvement of Social Welfare Training: Contri- second document is a report prepared by I L O o n an
butions from Related Fields. January 1977. inter-agency evaluation of thesefirstcomprehensive
29 p . $2. (UN/ST/ESA/58-E.77.IV.1.) missions undertaken with the full co-operation of the
The Expert G r o u p Meeting o n the Improvement of governments concerned.
Social Welfare Training met at United Nations
Headquarters from 13 to 22 October 1975. A s a basis Meeting Basic Needs. Strategies for Eradicating Mass
for the meeting, five studies were undertaken in dif- Poverty and Unemployment. Conclusions of the
ferentfieldsclosely related to social welfare, i.e. public World Employment Conference, 1976. 1977.
health and family planning, rural community devel- 64 p . 7.50 Swiss francs. I L O , G e n e v a .
opment/agricultural extension, urban community de- This volume o n the World Employment Conference
velopment, labour welfare/personnel management, convened by ILO in June 1976 contains a review of
and non-formal education. T h e purpose of these the preparatory phase, the discussions and outcome,
studies w a s to examine the knowledge and skills together with the conclusions and p r o g r a m m e of
required of workers in thesefieldso n the premise that action for a basic-needs strategy adopted b y the
an identifiable core of shared content could open conference.
 Materials from the United Nations system:
an annotated selection
Political questions
Decolonization
Southern Rhodesia. Working paper. March 1977.
24 p . ( U N / A / A C . 1 0 9 / L . 1 1 4 0 . ) With 8 statistical
tables.
[St.] Describes land and people, developments in
the Zimbabwe liberation movement prior to Sep-
tember 1976, attempts at a peaceful settlement; armed
liberation struggle. Southern Rhodesia aggression
against Mozambique; brutality in Southern Rhodesia;
evasion of sanctions.
H u m a n rights
The Role of Youth in the Promotion and Protection of
Human Rights. Channels of Communication French equivalents.
with Youth and International Youth Organiz-
ations. December 1976. 33 p . ( U N / E / C N . 4 /
1241.)
Report of the Ad Hoc Advisory Group on Youth on
its third meeting at United Nations Headquarters
from 21 July to 1 August 1975. The report studied
over a three-year period the assessment of current
review of channels of communication between the
United Nations, youth and youth organizations; re-
view on implementation of previous advisory group
recommendations on United Nations youth policies
and programmes; development of a representative
forum for consultation between the United Nations
and youth and international youth organizations;
development of a comprenhensive United Nations
policy and co-ordinated programmes to meet the
needs and aspirations of youth.
Question of the Violation of Human Rights and Fun-
damental Freedoms, Including Policies of
Racial Discrimination and Segregation and of
Apartheid, in All Countries, with Particular
Reference to Colonial and Other Dependent
Countries. January 1977. 5 p . ( U N / E / C N . 4 / N G O / For each country appearing in this inventory, the
193.) Written statement submitted by A m - following aspects of the social sciences are described:
nesty International, a non-governmental or-
ganization in Category II consultative status.
Amnesty International strongly endorsed the rec-
ommendation of the United Nations Sub-Commission
on prevention of discrimination and protection of
minorities that the Commission on H u m a n Rights
undertake a thorough study into human rights viol-
ations in Uganda. It outlines the main types of human Planning for Satellite Broadcasting. 1976. 71 p . 8 F
rights violation in Uganda from 1971 to 1976 with
some recent examples. It concerns removal of consti-
tutional and legal rights, commissions of inquiry,
arrests and killings by the security forces and torture. Papers on Mass Communication, N o . 78.)
563
Education, science, social sciences,
communication
Education
World Directory of Schools for Medical Assistants/
Repertoire Mondial des coles d'Assistants
Mdicaux, 1973. 1976. 112 pages. 29 Swiss
francs. Bilingual: English/French. W H O ,
Geneva.
The directory contains data up to 1973 on schools for
medical assistants in those countries or areas whose
governments have communicated the requisite in-
formation to W H O .
The Vnesco-IBE Education Thesaurus. 1975. 278 p .
32 F . Unesco, Paris.
A faceted list of terms for indexing and retrieving
documents and data in thefieldof educationwith
Study Abroad. XXIst edition 1977-1978/1978-1979/
Etudes l'trangerEstudios en el Extranjero.
1977. 560 pages. 28 F . Unesco. International
scholarships. International courses.
Science
Marine Affairs: Register of Courses and Training Pro-
grammes. December 1976. 157 p . $10. (UN/ST/
ESA/54-E.77.II.A.2.)
A n international survey of academic and research
institutes offering courses and training programmes
in marine technology, ocean engineering, coastal
zone management, the application of economics to
the marinefield,and coastal zone protection laws and
regulations.
Social Sciences
Social Sciences in Asia I. Bangladesh, Iran, Malaysia,
Pakistan, Thailand. March 1976. 54 p . 8 F .
Unesco. (Reports and Papers in the Social
Sciences, N o . 32.)
historical background; institutional framework of
teaching and research; social science development;
major issues and perspectives, and recommendations
for regional and international co-operation.
Communication
Unesco.
The Indian Instructional Television Experiment, by
Romesh Chander and Kiran Karnik. (Reports and
 Books received
Generalities, fundamentals
of knowledge and culture
C O U N C I L O F E U R O P E . Cultural DevelopmentDvelop-
pement Culturel: Thesaurus, prepared by Jean
Viet. Strasbourg, Council for Cultural C o -
operation, 1976.333 p .
D E L A H A Y E , Yves. La Frontire et le Texte: Pour
une Smiotique des Relations Internationales.
Paris, Payot, 1977. 249 p . , tables, figs.,
bibliog., index. 55 F .
W I L D E N , Anthony. System and Structure: Essays
in Communication and Exchange. London,
Tavistock Publications, 1977 (first published
1972). 5.25. G U B E R T , Renzo. L'Identificazione tnica: Indagine
Psychology
A N C E L I N - S C H T Z E N B E R G E R , A . Le Corps et le Groupe: H A R - P A Z , Haim; H A D A D , Menashe. Studies, Em-
Les Nouvelles Thrapies de Groupede la
Gestalt la Bio-nergie, Aux Groupes de Ren-
contre et la Mditation, collab. M . - J . Sauret.
Toulouse, Edouard Privat, diteur, 1977.
336 p . , illus.,figs.,graphs, bibliog., index.
64 F . (ducateurs.)
W A L K E R , Nigel. Behaviour and misbehaviour: explan-
ations and non-explanations. Oxford, Basil
Blackwell, M a y 1977. 154 p., bibliog., index.
5.
Social sciences
A B T , Clark C . (ed.). The Evaluation of Social Pro-
grams. Beverly Hills and London, Sage Pub-
lications, 1977. 512 p . ,figs.,tables, index.
16.
A N N U A L N O R T H AMERICAN MEETING, DENVER, C O L . ,
F E B . 21-25, 1977: The General Systems Para-
digmScience of Change and Change of
ScienceProceedings, co-ordination by Jay
Int. Soc. Sei. J., Vol. XXLX, N o . 3, 1977
Dixon White. Washington, Society for Gen-
eral Systems Research, 1977. 522 p . , figs.
$15.
Sociology
A L - Q A Z Z A Z , Ayad. Women in the Middle East and
North Africa: An Annotated Bibliography.
Austin, Center for Middle Eastern Studies,
June 1977. 178 p . , index. $6.50. (Middle East
Monographs, N o . 2.)
F R O M O N T , Jacques J. Le Schma Sociologique: Un
Essai de Systmatisation et de Schmatisation
de la Ralit Sociale. Bruxelles, ditions
Labor, 1976. 295 p . ,figs.,bibliog.
Sociolgica in Vn'area Plurilingue del Trentino
Alto Adige. Udine, Edizioni del Bianco/
Istituto di Sociologia Internazionale di Gori-
zia, 1976. 520 p., tables,figs.,graphs.
ployment and Leisure Activities Among Young
People. Tel Aviv, Tel Aviv-Yafo Munici-
pality Research and Statistical Department,
October 1976. 74 p. (Researches and Surveys,
N o . 50 in English and Hebrew.)
HEISE, David R . (ed.). Sociological Methodology,
1977. San Francisco and London, Jossey-
Bass, 1977. 320 p.,figs.,tables, index. 9.40.
JANSSEN-JURREIT, Marielouise. Sexismus: ber die
Abtreibung der Frauenfrage. Mnchen, Carl
Hanser Verlag, 1977. 755 p . , index.
K R L L , Marianne. Schizophrenie und Gesellschaft.
Mnchen, Verlag C . H . Beck, 1977. 214 p . ,
gloss., index, bibliog. D M . 1 4 . 8 0 .
L E N E R O - O T E R O , Luis (ed.). Beyond the Nuclear Family
Model: Cross-cultural Perspectives [Papers
presented at the working sessions of the
Family Research Committee of the Inter-
national Sociological Association, in the
World Congress of Sociology, 8th, Toronto,
August 1974]. Beverly Hills, Sage Publications
Inc., 1977. 226 p . ,figs.,tables. Cloth, 8;
paper, 3.95.
 Books received 565

Statistics, demography Conference Report, Airlie House, Warrenton,

7-10 Oct. 1976. Muscatine, Iowa, T h e
Stanley Foundation, [1977]. 77 p .
H U N G A R Y . H U N G A R I A N CENTRAL STATISTICAL OFFICE.
Statistical pocket book of Hungary, 1976.
Budapest, Statistical Publishing House, 1976.
210 p . , tables, graphs, maps. Economics
I N - J U N G W H A N G (ed.). Management of Family Plan-
ning in Asia: Concepts, Issues and Approaches. Aproximacin al Estudio de la Regin de Ponferrada:
Kuala Lumpur, Asian Centre for Develop- la Poblacin. Sistema y Jerarquia Urbanas, por
ment Administration, 1976. 423 p . , figs., Jos Maria Garca Alonso. Madrid, Ediciones
tables, bibliog. y Publicaciones Populares, 1976. {De Econo-
ma: Revista de Estudios Economico-Sociales,
S T O N E , Leroy O . ; M A R C E A U , Claude. Canadian Popu-
Vol. 29, N o . 139, p . 531-756.)
lation Trends and Public Policy through the
1980s. Montreal and London, McGill- B E N E T , Ivn; G Y E N I S , Jnos (eds.). Economic
Queen's University Press, 1977. 109 p . , Studies on Hungary's Agriculture. Budapest,
charts, bibliog., index. Cloth, $8.50; Paper, Akadmiai Kiad, 1977. 193 p . ,figs.,tables,
$4. bibliog. $12.
B U R E A U I N T E R N A T I O N A L D U T R A V A I L . Les Jeunes Face
aux Conditions et au Milieu de Travail.
Genve, Bureau International du Travail,
Political science 1977. 40 p . 12.50 Swiss francs.
C S I Z M A D I A , Ern. Socialist Agriculture in Hungary.
La Mujer y la Poltica. Revista del Instituto de Cien- Budapest, Akadmiai Kiad, 1977. $11.
cias Sociales, N o . 29, 1977. Barcelona, Dipu- 178 p., tables.
tacin Provincial de Barcelona, 1977. 421 p . D U R A N D , Michelle; H A R F F , Yvette. La Qualit de la
L E R N E R , Allan W . The Politics of Decision-making: Vie: Mouvement cologiqueMouvement Ou-
Strategy Cooperation and Conflict. Beverly vrier. Paris and L a Haye, Mouton, 1977.
Hills and London, Sage Publications, 259 p . , illus., bibliog.
March 1977. 213 p . , tables, bibliog. Cloth
8.65; Paper 4.55. (Sage Library of Social
Research, Vol. 34.) L a w , jurisprudence
O Legislativo e a Tecnocracia: Seminario sobre Legis-
lativo e Desenvolvimento, Agosto de 1974,S Z A S Z , Thomas S. La Loi, la Libert et la Psychiatrie.
organizado por Candido Mendes. Rio de Trans, by Monique Manin. Paris, Payot,
Janeiro, Imago Editora Ltda., conjunto Uni- 1977. 336 p . 69 F .
versitario Candido Mendes, 1975. 269 p . Tendencias di Pensamento Jurdico: Coletanea de Ar-
PACIFIC SCIENCE C O N G R E S S , 13th, VANCOUVER, tigos do International Social Science Journal,
A U G U S T 1975. Mankind's Future in the Pacific: v. 22, n. 3, 1970, Unesco. Trans. Ailton
the Plenary and Special Lectures (ed.), Robert Benedito de Souza. Rio de Janeiro, Instituto
F . Scagel. Vancouver, University of British de Documentao Editora de Fundao
Columbia Press, 1976. 198 p . , tables, figs., Getulio Vargas, 1976. 252 p . , index.
bibliog.
PILLAI, Devadas S. (ed.). Aspects of Changing India.
Bombay, Popular Prakashan, 1976. 414 p. Social relief and welfare
100 rupees.
P U G W A S H CONFERENCE O N SCIENCE A N D W O R L D H A R - P A Z , Hayim; W O L I N S , Martin (eds.). Young
AFFAIRS, 26th, M L H A U S E N , G . D . R . , 26- Adults on Welfare: Trends, Objectives and
31 A U G . 1976. Disarmament, Security and Expectations. Tel Aviv, Tel Aviv-Yafo M u -
Development: Proceedings [London], Pugwash nicipality, Department of Research and Stat-
Conference, 1977. 223 p. istics, January 1977. 79 p . (English and
S T O C K H O L M INTERNATIONAL P E A C E R E S E A R C H INSTI- Hebrew.)
TUTE. World Armaments and Disarmament: O R G A N I S A T I O N M O N D I A L E D E L A S A N T . Rapport du
SIPRI Yearbook 1977. Stockholm, Almqvist Directeur Rgional: Juillet 1975 Juin 1976.
& Wiksell, 1977. xvi+421 p . , tables, figs., Copenhague, Bureau Rgional de l'Europe,
index. Approx. 140 Swedish kronor. 1976. 108 p . , illus.
T H E S T A N L E Y F O U N D A T I O N . Arms Limitation and R E N U C C I , Daniele. Conditions de Vie des Retraits du
Disarmament. Seventh Strategy for Peace: Btiment en 1975. Cagnes-sur-Mer, Caisse
 566
Nationale de Retraite des Ouvriers du Bti-
ment et des Travaux Publics, Mars 1977.
151 p . , graphs, tables, bibliog. 25 F . (Do-
cuments d'Information et de Gestion,
Mars 1977.)
T H U R S Z , Daniel; V I G I L A N T E , Joseph L . (eds.). Meet-
ing Human Needs, 2: Additional Perspectives
from Thirteen Countries. Beverly Hills and Rossi, Ino; B U E T T N E R - J A N U S C H , John; C O P P E N H A V E R ,
London, Sage Publications, 1976. Cloth, 11;
paper, 4.95 (Social Service Delivery System:
A n International Annual, volume 2.)
UNITED STATES. DEPARTMENT OF HEALTH, EDU-
C A T I O N A N D W E L F A R E . Women and their
HealthResearch Implications for a New Era,
San Francisco, 1-2 Aug. 1975: Conference Pro-
ceedings. E d . Virginia Olesen. San Francisco,
National Center for Health Services, 1976.
103 p . , tables.
Education
F O G E L , Barbara R . A Handbook for PlannersDesign
for Change: Higher Education in the Service
of Developing Countries. N e w York, Inter-
national Council for Educational Develop-
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L E V E U G L E , Jean. Devenir Animateur et Savoir Ani-
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Pratiquer l'Animation. Toulouse, Edouard
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BTEILLE, Andr. Inequality among Men. Oxford,
Basil Blackwell, 1977. 178 p . index. Cloth,
6.50; paper, 3.25. (Pavilion Series: Social
Anthropology.)
J E A N , Maria Teresa; S E R R A N O , Carlos; C O M A S , Juan.
Data Antropomtrica de Algunas Poblaciones
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Past topics1

F r o m 1949 to the end of 1958, this Journal appeared under the n a m e of Inter-
national Social Science Bulletin, not all issues of which were devoted to a
main topic.
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Vol. XI, 1959 N o . 2. Compromise and conflict

N o . 1. Social aspects of mental health* resolution
N o . 2. Teaching of the social sciences N o . 3. Old age
in the U . S . S . R . * N o . 4. Sociology of development
N o . 3. The study and practice of in Latin America
planning*
N o . 4. N o m a d s and nomadism Vol. XVI, 1964
in the arid zone* N o . 1. Data in comparative
research*
Vol. XII, 1960 N o . 2. Leadership and economic
N o . 1. Citizen participation in growth
political life* N o . 3. Social aspects of African
N o . 2 . The social sciences and resource development
peaceful co-operation* N o . 4. Problems of surveying
N o . 3. Technical change and political the social sciences and
decision* humanities
N o . 4 . Sociological aspects of leisure*
Vol. XVII, 1965
Vol. XIII, 1961 N o . 1. M a x Weber today/Biological
N o . 1. Post-war democratization aspects of race*
in Japan* N o . 2. Population studies
N o . 2 . Recent research on racial N o . 3. Peace research*
relations N o . 4. History and social science
N o . 3. The Yugoslav c o m m u n e
N o . 4 . The parliamentary profession Vol. XVIII, 1966
N o . 1. H u m a n rights in perspective*
Vol. XIV, 1962 N o . 2. Modern methods in
No. 1. Images of w o m e n in society* criminology*
No. 2. Communication and N o . 3. Science and technology
information as development factors*
No. 3. Changes in the family* N o . 4. Social science in physical
N o . 4. Economics of education* planning*

Vol. XV, 1963 Vol. XIX, 1967

N o . 1. Opinion surveys in developing N o . 1. Linguistics and
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N o . 2. The social science press
N o . 3. Social functions of education*
N o . 4 . Sociology of literary creativity*
Vol. XX, 1968
N o . 1. Theory, training and practice
in management*
N o . 2. Multi-disciplinary
problem-focused research*
N o . 3. Motivational patterns
for modernization
N o . 4 . The arts in society*
Vol. XXI, 1969
N o . 1. Innovation in public
administration*
N o . 2. Approaches to rural problems*
N o . 3. Social science in the
Third World*
N o . 4. Futurology*
Vol. XXII, 1970
N o . 1. Sociology of science*
N o . 2. Towards a policy for social
research
N o . 3. Trends in legal learning
N o . 4 . Controlling the human
environment
Vol. XXIII, 1971
N o . 1. Understanding aggression
N o . 2. Computers and documentation
in the social sciences
N o . 3. Regional variations in
nation-building
N o . 4 . Dimensions of the racial
situation
Vol. XXIV, 1972
N o . 1. Development studies
N o . 2. Youth: a social force?
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N o . 3. The protection of privacy
N o . 4 . Ethics and institutionalization
in social science
Vol. XXV, 1973
N o . 1/2. Autobiographical portraits
N o . 3. The social assessment
of technology
N o . 4 . Psychology and psychiatry
at the cross-roads
Vol. XXVI, 1974
N o . 1. Challenged paradigms in
international relations
N o . 2 . Contributions to
population policy
N o . 3. Communicating and
diffusing social science
N o . 4 . The sciences of life and of society
Vol. XXVII, 1975
N o . 1. Socio-economic indicators:
theories and applications
N o . 2 . The uses of geography
N o . 3. Quantified analyses
of social phenomena
N o . 4 . Professionalism in flux
Vol. XXVIII, 1976
N o . 1. Science in policy
and policy for science*
N o . 2 . The infernal cycle of armament
N o . 3. Economics of information and
information for economists
N o . 4 . Towards a new international
economic and social order
Vol. XXIX, 1977
N o . 1. Approaches to the study of
international organizations
N o . 2. Social dimensions of religion
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