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1586 Book Reviews

I believe this volume could be reduced in size significantly Otherwise it is a good teaching and practical volume. At
by omitting such general discussions of health policy and $10.95, Assessing Child Survival Programs . . . might not be
program management covered in chapters 1, 2, 7 and 8. affordable in most African countries where commu-
Actually all sections covering ‘integrated health services’ nity/public health training and practice is becoming increas-
‘decentralization’, ‘management system’, etc. could have ingly popular.
been more coherent and probably more suitable in a differ-
ent book. They appear to be not only unnecessary in this
volume, but also an after-thought. The volume could have USAID /Tanzania F. M. MBURU
been more focused on LQAS, its power, relevance, robust- P.O. Box 9130
ness and superiority without these extraneous discussions. Dar es Salaam, Tanzania

Who Plays? Who Pays? Who Cares?: A Case Study in from the late 1950s to the mid 196Os,was one of growth and
Applied Sociology, Political Economy, And the Community expansion funded from surpluses within the state sector of
Mental Health Centers Movement, by SYLVIA KENIG. Bay- the economy. It was characterized by a strong consensualist
wood Publishing Company, Amityville, NY, 1992. 221 view in which communities were perceived as geographically
pp., S28.95 (hardback), $21.75 (paperback). defined ‘catchment areas’, without attention to economic,
political or cultural issues. Some authors even used the term
If the ambiguous title and lengthy subtitle of this book don’t ‘community’ to refer to local physicians who could benefit
immediately make clear its purpose and subject, don’t from their expert services, implying that patients were not
expect things to improve instantly once you begin to read part of the ‘community’ being served.
it. As the author states in the first sentence of her introduc- The second phase identified by Kenig coincided with the
tion “This is a book of many parts”. Like a home appliance period of social unrest that extended from the mid 1960s
that arrives in a cardboard box labeled “some assembly until the early 1970s. Within the broader context of social
required”, the many parts of the book don’t always seem to activism, the priests of the CMHC movement were chal-
fit together smoothly, it doesn’t always follow the “assembly lenged by prophets whose conflict theory orientation led
diagram” provided in its introduction and it may leave the them to challenge even the most basic assumptions about
reader wondering whether s/he has put it together properly. mental health, the nature of mental illness, and the goals and
Despite these caveats, I believe that Kenig has produced a methods of mental health services delivery. Kenig describes
book that is worth the investment of time and effort the works of Richard Kunnes by noting, “here the assump-
necessary to assemble all of the pieces. tion is that psychiatrists represent simply one set of con-
This book is the first in a new series entitled “Critical trollers, joining with other control agents in order to uphold
Approaches in the Health Social Sciences” forthcoming the culture of an elite group.” “. These (CMHC)
from Baywood Publishing. Essentially it is both a social programs maintained the establishment’s status quo.
history of the Community Mental Health Center (CMHC) They depoliticized issues, ‘psychiatricizing’ them instead”
movement in the United States, written from the critical (p. 135). Prophetic views promulgated during this phase saw
perspective of class based conflict theory, and an applied ‘community’ as defined by common political and economic
sociological analysis of how the changing meanings attached interests. Community health required community awareness
to the term ‘community’ reflect economic and social forces and the community’s control of its own political, social and
within the CMHC movement and within the broader so- economic realities. Thus, to reformers applying conflict
ciety. Much of the book documents the tensions and theory, ‘community’ was defined by the class struggle.
competition between consensualist social theories and confl- Despite a battle for control of the movement between the
ict theories within the CMHC movement and the impact of consensualist and conflict perspectives, the CMHC move-
broader political and economic forces on this interaction. ment continued to grow through most of this second phase,
According to Ken&, consensualist or “priestly” views in- in part by translating societal unrest into a mandate to
itially defined the role of community mental health as the expand in order to serve a more diverse clientele.
reaching out of traditional psychiatric medical services to Kenig’s third phase coincided with greater austerity in
enhance social integration and to treat mental illness in the federal spending and is described as one characterized by the
community. At the opposite extreme, a pure conflict or broader social theme of ‘accountability’. Good intentions
“prophetic” view perceived community mental health ser- were no longer accepted as justification for government
vices as a potent mechanism for undermining a capitalist funding and the CMHC movement became subject to
system that produced mental illness by sacrificing the well- pressures to prove its worth. Program evaluation became
being of non-dominant classes in order to serve the interests formalized and ideological debate was suppressed and sup-
of the ruling class. Following an introductory chapter, the planted by atheoretical critiques and consumerist move-
book begins by presenting a brief comparison and contrast ments focusing on improving services delivery. According to
of models of applied social theory derived from consensual- Kenig, definitions of community typically returned to a
ist and conflict perspectives. This is followed by social- consensualist base, incorporating more diverse consensualist
historical examinations of social psychiatry and of the models but usually ignoring the concepts of community
CMHC movement. Kenig has identified three historical inherent in conflict theor&
phases in the CMHC movement and she evaluates the From Kenia’s perspective, the CMHC movement effec-
meaning attached to ‘community’ in the context of battles tively ended in the early 1980s when Reagan’s block grant
and compromises between these conflicting views within the programs mandated the return of outpatient mental health
political and economic context of each phase. services to local control. Reagan’s defederalization often
The bulk of the book is devoted to discussion of the three channeled paying patients into the profit sector and in
phases of the CMHC movement and scrutiny of the mean- many areas of the nation abandoned poor patients to the
ings ascribed to community in each phase. The first phase, streets. Kenig states that the concept of community largely
Book Reviews 1587

disappeared from the mental health literature at this time. the author’s meanings are often clouded. Examples range
This certainly seems consistent with the emphasis on indi- from obvious misspellings “confrontatins” (p. 175) to ap
vidualism and self-interest that characterized much of the parent misuse of spell checking software to substitute incor-
popular and political writings of the 1980s. rect words, e.g. “. . to reflect the emerge of interested
The book ends with a brief chapter that attempts to apply groups” (p. 201) “. . . a graduure evolutionary process was
a sociology of knowledge perspective to applied sociology. needed” (p. 162) and (my favorite) “. . . the Me&l Patients
Its conclusions, interesting-if a bit mundane, are that Liberation Project” (p. 192) (italics added for emphasis).
competing and incompatible social theories coexist in their Indeed, the result is often entire sentences that are non
application outside their disciplines, and that while no one sequiturs: “The idea that disequilibrium, conflict, and
theory completely supplants its competitors, theories that change are endemic to the given system, are in fact is basic
serve dominant political and economic systems are usually social process, is not considered” (p. 109). The frequency of
favored. As macro social and historical changes occur, the such errors throughout the book adds a level of confusion
frequency of application and relative degree of influence and irritation for the reader that is unacceptable and
shifts among competing theoretical approaches. Kenig con- demands better performance from the Series Editor and/or
cludes that it is these macro political and economic forces publisher. Such sloppiness seems especially inappropriate
and not scholarly discourse that determine the relative when such a small paperback book is priced at over $20. The
power of competing applications of social theory. topic, the author’s scholarly efforts, and the purchaser each
A review of this book would be incomplete without one deserve better.
final, nontraditional criticism. While it may be atypical to
comment on issues of spelling, usage and proofreading in University of Florida LEEA. CRANDALL
anacademic book review, an exception must be made here Gainesville
because this book is so rife with careless editing errors that FL 32610, U.S.A.

Native Society and Disease in Colonial Ecuador, by SUZANNE native population, as well as the development of new social
AUSTINALCHON.Cambridge University Press, Cambridge, institutions and customs to cope with the demands of the
1991. $39.95, 151 pp. colonial government. A particularly interesting section of
this chapter discusses changing concepts of disease in native
In 1992, Eric Wolf challenged anthropologists to study more society. It was considered that now both the European and
deeply the historical events that have shaped the lives of the the native gods had the potential to inflict disease; thus, two
populations this discipline has traditionally studied. In sets of rituals were developed.
relation to New World indigenous populations, a particu- The 1690’s, however, brought new epidemics, as well as
larly critical aspect of study is the history of disease and its natural disasters, with serious demographic and economic
social and cultural effects. These issues have been explored effects. The eighteenth century was characterized by a
for a variety of other New World populations by archaeol- declining Indian population and a shrinking economy.
ogists, physical anthropologists, and ethnohistorians. In this However, this period also reflected the development of
case, Suzanne Austin Alchon, a historian, has undertaken immunological resistance among the indigenous population
the task of clarifying these issues in the context of colonial to some of the illnesses introduced by the Europeans.
Ecuador. The focus is on the relationship between indige- Concurrently, an increase in native opposition to colonial
nous peoples of northern Ecuador and disease, particularly rule is seen, related to the increasing demands placed by the
those diseases introduced in the sixteenth century by Eu- colonial authorities on a much reduced Indian population.
ropeans. She seeks to demonstrate the biological adapta- It is suggested that native healers played an important part
bility and resilience of the indigenous populations, and in organizing this opposition.
ultimately to show how the history of biological adaptation The author concludes that in order to understand the
reveals much about people’s political and social experience colonial history of the indigenous people of Ecuador, it
under colonial rule. is necessary to understand the relationship of their
The first chapter addresses the pre-colonial situation, with biological experiences and their political and social his-
emphasis on social and physical setting, as well as a tory. Illness was in these situations, not only physiological
demographic history of the area before the Spanish con- but also political. The issue, she states, is that disease
quest in 1534. The recent Incan conquest of parts of introduction itself, is not a factor sufficient to itself explain
Ecuador had caused some declines in population, as had the dramatic decline of Indian populations. Rather, it was
epidemics of European diseases which occurred as early as the combination of disease and the simultaneous loss of
1524. The next chapter examines indigenous concepts about control over economic and social resources which was
health, illness, and healing. Illnesses were seen as the result critical.
of biological and cosmic imbalances, and cures focused on In general, the book is well written, and the argument and
restoring the system to equilibrium, through the use of documentation clear. A more serious flaw is the extent to
offerings to the gods, rituals and medicinal plants. which the author’s final point about the role of loss of
The next issue addressed is attempts by the Europeans to economic and social control of resources is not developed as
deal with illnesses in the sixteenth century, both in their own fully as would have been optimal. Nevertheless, the book
and in the indigenous population. These included the devel- will be of value to a variety of scholars. Medical anthropol-
opment of policies and laws to protect public health, as well ogists concerned with contemporary issues of health in
as the establishment of hospitals. High levels of mortality in Ecuador will find much of use, as will scholars more
the Indian communities were related not only to the Euro- generally concerned with the issue of the role of illness in
pean diseases themselves, but also to malnutrition, mistreat- cultural and social change.
ment, declines in fertility, and the breakdown of traditional
indigenous systems of social services. The seventeenth cen- University of South Florida ROBERTAD. BAER
tury, discussed in Chap. 4, was a period of recovery for the Tampa, FL 33620, U.S.A.