International Journal of Social Determinants of Health and Health Services

This article critically assesses the ideology of industrialism in light of Ivan Illich's Medical Nemesis. The paper is divided into three sections. The first section is a description of the main features of that ideology, the most prevalent and influential one used in sociological literature to explain the state both of Western societies and of our health services. Also in this section, it is shown how these features appear in Illich's analysis of our societies, of our health services, and of the different clinical, social, and structural iatrogeneses that health services create. The second section examines the assumptions underlying Illich's analysis and discusses their validity to explain the nature and function of our Western health services and their iatrogenic effects. Where Illich's explanations are considered invalid, alternative explanations are presented. Among them, it is postulated that it is not industrialism, but the assumedly transcended category of capitalism that is the cause of the social and structural iatrogeneses. The third section discusses the political implications of Illich's analysis, in a moment when our Western societies are supposedly in crisis.

This paper presents a new technique for describing inequality of access to medical care. Access is described by the empirical relationship between need and the probability of entering the health care system for treatment. The need-entry probability relationship for one population group is compared with that for another population group to determine the extent of access differentials (differences in entry probabilities) at varying levels of need. As an illustrative application, the technique is employed to describe access differentials by economic class in six different geographic areas located in five different countries (Canada, England, Finland, Poland, United States) with differently structured health care systems. Although the findings for adults varied considerably from area to area, the access differentials among children were surprisingly consistent and unrelated to health care system structure. In particular, it appears that higher family income is associated with greater access to medical care among children at all levels of need. The paper concludes with suggestions for further applications of the proposed technique to problems of monitoring and evaluating the effectiveness of policies aimed at reducing the extent of access inequality.

There are three distinct approaches to the analysis of women's position in society, and thus of women's relation to the health care system. Liberal feminists seek equal opportunity “within the system,” demand equal opportunity and employment for women in health care, and are critical of the patronizing attitudes of physicians. Radical feminists reject “the system” as one based on the oppression of women and seek to build alternative structures to better fill their needs. They see the division between man and woman as the primary contradiction in society and patriarchy as its fundamental institution. They have initiated self-help groups and women's clinics to extend the base of health care controlled by women in their own interests. Marxist-feminists see the particular oppression of women as generated by contradictions within the development of capitalism. Women's unpaid labor at home and underpaid labor in the work force both serve the interests of the owners of capital. The health care system serves these same interests; it maintains and perpetuates the social class structure while becoming increasingly alienated from the health needs of the majority of the population.

Originally, many of the initiators of the World Population Conference, which took place in Bucharest in 1974, had hoped that the Conference would imply a final breakthrough for the view that family planning measures should be given top priority in all less-developed countries. In fact, however, the Plan of Action passed by the Conference contains very little relating to population and family planning. Instead, the document is dominated by wordy phrases about the necessity of attaining social and economic development in those countries. Will the insight that family planning programs work efficiently only if they are an integral part of programs for the social and economic development of a country lead to such programs being realized? There is every reason to doubt that the Plan of Action will have any such effect. The reasons for the underdevelopment of Third World countries cannot be removed through such United Nations resolutions.

In the People's Republic of China, family planning is widely accepted, especially in the towns, and now also among the rural population. Limiting the number of children is considered part of China's development effort. China is a less-developed country that is in the process of rapid social and economic development. The issue at stake in other Third World countries is how to achieve a similar development. As soon as this goal is achieved, family planning efforts are meaningful and have a chance of success. The experience of China demonstrates that even there it took time before the efforts succeeded. There are many Third World countries that could, without much difficulty, support a population considerably larger than the present one. But there are no doubt also a number of countries where the population is already so large that a continued population increase would be harmful. The need to achieve rapid development becomes increasingly urgent, not in the least to make it possible to attain a reduced population growth. The sad truth is that so little development takes place in those countries. Without social and economic development, the present rapid population increase will continue in those countries where there is already an overly dense population.

Living and working through the period since the British National Health Service began in 1947, the author describes his experiences as a family and general practitioner and in particular notes the effects and non-effects of the reorganization that took place in the National Health Service in 1974.

The initial postwar development of new towns in Britain took place at a time when the present British National Health Service was in its infancy, and few attempts were made to integrate health service planning into the overall planning process. The more recent new towns have been the object of better social planning and, at the same time, the National Health Service has been substantially unified, at first functionally and, in 1974, administratively. In consequence, attempts have been made to use the opportunities which such towns present for planning health services in a comprehensive and integrated manner. The evolution of a planning and implementation structure for health services in Milton Keynes, a new town with a target population of 250,000, is described, together with some of the implications for the administratively unified National Health Service which came into being in 1974.

The National Health Planning and Resources Development Act of 1974 in the United States demonstrates a growing determination in Congress to motivate the system of health services toward greater efficiency in utilization of resources. The Act was designed to overcome some of the weaknesses in earlier planning legislation. More complete coverage and more functional local jurisdictions for planning should result. The Act provides better financial support, and more effective incentives and inducements to assure adherence to plans. Concern is expressed about aspects of the legislation which the authors feel may deserve consideration. The principle of delegating responsibility to voluntary agencies for disbursement of public funds is questioned, and the authors suggest that local public health authorities apply for designation as planning agencies. Reservation is expressed about the adequacy of regional organization as provided by the Act to accomplish its purposes, and the authors recommend demonstrations of regional administrative agencies to implement plans developed by Health Systems Agencies. Failure to incorporate the provision of the House planning bill to set up a national health policy council in the Act is considered unfortunate. Persistence in pursuing the course outlined in the Act is urged.

Between 1910 and 1970 the number of physicians in the United States increased 2.5 times, in Soviet Russia almost 25 times. The number of physicians per constant unit of population remained fairly stable in the United States, rising slightly in the last few years. In the U.S.S.R. that number increased 16 to 18 times, and now stands about 50 per cent higher than in the United States. About 10 per cent of American physicians are women; in the U.S.S.R. it is about 70 per cent. Neither society has resolved the problem of deploying physicians to the rural areas. American physicians are more specialized than their Soviet colleagues. The article concludes with general remarks about the two health systems, pointing out resemblances and divergences. The hypothesis of a possible “convergence” is entertained.

Among the changes that have been brought about in health delivery in the People's Republic of China, the introduction of the barefoot doctor has been one of the most important and effective ways that the government has devised to radically alter the concept of health care. Through close identification with the community in terms of recruitment, training, and practice, the barefoot doctor is a concrete manifestation of the ideological principles of following the mass line and being self-reliant. This paper focuses on the building of rural health services, with special reference to the training of the barefoot doctor as the first-level contact person in primary care in the communes. It describes the training programs in a school of public health and the career mobility possible to the barefoot doctor in joining the ranks of medical practitioners.

International health agencies face major changes requiring basic adjustments in approaches and values. The ethical issues include moral criteria for allocating scarce resources, relation of health to population growth and development, iatrogenic social consequences of health measures, and inappropriate transfer of technology. A proposed new style of international health work is summarized in five principles and ten guidelines. The principles are: development from below; a role shift from adviser collaborator; sequential research, demonstration, and implementation; concentration on problems of motivation; and partnership in approaches to mutually shared complex problems.

Relationships between selected socioeconomic characteristics of counties and infant mortality rates are examined. There are two research objectives: to determine the extent to which low family income, low education, sound housing, and the percentage of blacks “directly” and “jointly” relate to neonatal and postneonatal mortality rates; and to determine the degree to which a zero-order correlation between a given socioeconomic measure and general infant mortality is transmitted by neonatal and postneonatal mortality rates, respectively. Data corresponding to 2237 counties in the United States are analyzed by path analysis. Results show that the percentage of blacks and low education are two variables which have appreciable direct effects on both components of infant mortality. These two factors are also responsible in large measure for gross associations between low family income, sound housing, and rates of infant loss. On the basis of this study it is estimated that approximately two-thirds of the zero-order correlation between a given county measure of socioeconomic status and infant mortality occurs through the postneonatal component. Implications of these findings are discussed.