Measuring the Social Benefits of Medicine, edited by GEORGE TEELING SMITH. Office of Health Economics, London 1983. 175 pp. f7.50

This book is a collection of papers presented at a meeting organised by the Office of Health Economics (OHE) in May 1983. Though Brutish authors domtnate. the contributions are not slanted towards any particular type of health care system.

The subject of the meettng. whtch the title of the volume does not make entirely clear. is the social and economtc (as opposed to climcal) evaluation of pharmaceuticals. as well as other types of health care interventions. Contributors fall into two groups-the health economists and the clinicians- with a broad unammity of opinion within each camp but considerable disagreement between them.

The framework underlytng the discussion IS cost benefit analysis. or as Alan Williams expresses it. “ensuring that the value of what IS gained from anv activity outweighs the value of what has to be sacrificed’.. The mam problem in applying this theoretically simple calculus is. of course, that many of the gams and sacrtfices cannot be readily measured. let alone uncontentiously valued. This problem is of little consequence. however, for the evaluation of those new drugs which bring about dramatic reductions in mortality and morbidity. Stnce benefits which can be more easily measured and valued. such as savings in health care re- sources and increases in marketed output, will be shown greatly to exceed costs. the ‘intangible’ benefits, parttcularly the value attached to tmprovements m health prr sr. are not needed for the drug to pass the cost-benefit test. They became merely Icing on the cake. As Nick Wells points out in hts contribution. though. the heyday of new wonder drugs is waning. and the benefits of new medicines are increasingly manifested in terms of improvements in the quality of life. i.e. the ‘intangibles’. It is thus becoming crucial that the tools to measure the social benefits of medicines be further developed for new drugs to compete with other therapies for scarce health care resources.

In theory the evaluatton of aspirin is no different from the evaluatton of acupuncture. but one must question whether all the authors in this volume would necessarily agree with the sentiments expressed m Professor Teeling Smith’s intro- duction or m the other papers by the host members of OHE. There is a running feeling throughout those articles that expenditures on drugs are a good thing and that the purpose of economic appratsal is to bring this out. We are reminded that . . . the British pharmaceutical manufacturers felt it important to establish the OHE. one of whose earliest objectives was IO prove that the social and economic benefits of medicmes justified their cost and rusk”. In another article the nation’s drug bill IS presented in a curiously favourable light: first expressed as a percentage of the iota1 cost of disease. and then on a per head of population basis com- pared with. among other things. per capita expenditure on defence. The main point. which. from the rest of their wrtttngs these authors clearly agree. is not the absolute size of the drugs bill but whether or not the benefits which tt generates exceed the topporrunny ) cost.

The first step in measurtng the social benefits of medicines or other interventions. is the measurement of health status. and all contributions to this volume are concerned to one extent or another with this Issue. .4s Jeremy Hurst states. -‘Improving health status IS a common goal for health servtce acrrcittes. yet wtthout a way of measuring thts yield. the value of activities cannot be compared formally. and the

BOOK REVIEWS

search for cfiiciency is hampered by ambiguity”. The health economists’ camp, to which Mr Hurst belongs. prefers what can be called ‘global’ indicdlors of health which attempt to weigh all the different dimensions of health to produce a single cardinal index. The clinicians, on the other hand. favour the less ambitious ‘health profile’ approach whtch measures health along its various dimenstons. but makes no attempt to assign specific weights (values) to different dimensions.

The appropriate measure of health status depends on the reason one wants it measured. The clinictan’s health profile can provide a complement IO other means of clinical assessment. but it is only the health economist’s global indices which, by attempting to make explicit those valu- ations which are implicit in all clinical decisions. will permit the cost-benefit framework to be applied and hence. increase the efficiency of resource allocation. This basic disagreement between the two camps IS confirmed in Professor Teeling Smith’s concluding comments which summarise the dis- cussion at the meeting.

Despite the differences m views presented. this book provides a useful introduction to the measurement of social benefits. Mike Drummond’s opening paper, while perhaps a bit familiar to those acquainted with economic appraisal. gives a clear and concise introduction to the cost-benefit approach which forms an essential backdrop to the papers which follow. There is, however, a tendency for later contributions to repeat various bits of the theory which. while relevant to the particular articles, become somewhat tedious when the book is read through. A short article by Alan Williams gives perhaps the clearest theoretical ex- position of the need for and potential uses of such indices, as well as the distinction between quantitative and qual- itative indicators. Rachel Rosser’s interesting contribution traces the history of the development of health status indices from the time of Hammurabi (I 792 BC) to-the present date.

On a more empirical level, the book contains numerous expositions of attempts to measure the social benefits of various dr ig and non-drug therapies. These are, in the main. lucid descriptions of the thinking behind previously pub- lished research and research in progress. Describing why particular methods were used. what alternatives were con- sidered, what the constraints were and the problems which arose, provides a refreshing alternative to the familiar format of methods, results and conclusions. In all cases the methodology is of greater interest than the results. which was the intention of the authors.

The overall impression left on reading this book is that on the one hand cardinal measures of health status can be of enormous value, and progress in the development of such measures is being made. At the same time there is still a very long way to go and measurement will not be costless. Given the potential for health status indices. one can only hope that a future meeting of this type will produce a less balanced result, and the clinicians will begin to join the economist’s camp.

Health Economics Research Untt lJnicersit>, qf Aberdeen. Scotland

DAVID COHEN

The Church and Healing, Studies in Church History. Volume 19. edited by W. J. SHEILS. Blackwell. Oxford, 1982. 440 pp. 536.00

These are interesting times for those who seek to understand the relationship between orthodox medicine and its spiritual

67

68 Book Reviews

competitors both from the Christian charismatic and pente- costal movements and from those disparate approaches to healing which generally derive from Eastern spiritual forms, known now as the holistic health movement. Some observers. like Marilyn Ferguson in The Aquarian Con- spirac? (J. P. Tarcher. Inc., 1980) predict that these streams are converging to produce an “amazing revitalization” of Western medicine:

Patients and professionals alike are beginning to see beyond symptoms to the context of illness: stress, society. family, diet, season, emotions. Just as the readiness of a new consituency makes new politics, the needs of patients can change the practice of medicine. Hospitals. long the bastions of barren efficiency. are scurrying to provide more humane environments for birth and death, more flexible policies. Medical schools, long geared to skim the cool academic cream, are trying to attract more creative. people-oriented students. Bolstered by a blizzard of research on the psychology of illness, practitioners who once split mind and body are trying to put them back together.

The less optimistic need only point to the recent legal battle for custody of the cancer-stricken daughter of a funda- mentalist preacher who refused to authorize chemotherapy or radiotherapy for her on the grounds that this conflicted with his faith commitments. In this case, as in many others. the competing claims of medical science and religious and quasi-religious approaches to wholeness are arbitrated in the courts without clear public consensus of their relative merits.

The Church and Healing offers a valuable historical perspective to this contemporary debate. The volume takes its title from the theme of the 1981/1982 conferences of the (British) Ecclesiastical History Society and consists of a selection of 22 papers along with an indispensable intro- duction by Terence Ranger, whose summary of the collec- tion’s concerns and conclusions brings a welcome analytical overview to the book’s wide-reaching topics. The essays address problems of scholarly interest to church, social, and medical historians and to medical anthropologists. While they restrict their focus primarily to Britain and British misston fields, the volume’s most vivid recurring theme is strikingly current: orthodox medicine’s legitimacy claims have been forcefully and often successfully challenged by widely diverse expressions of “popular religion” and “popular therapeutics”.

Several of the collection’s authors acknowledge Keith Thomas’ landmark Religion and Ihe Decline of Magic (Harmondsworth, 1973) yet challenge his thesis that. as the Reformation spread, Protestants left behind the venerable traditions of miraculous cures and turned to empirical science for answers to medical problems. Instead. engaging essays by M. Macdonald (“Religion, social change, and psychological healing in England, 160&1800”), H. D. Rack (“Doctors, demons, and early Methodist healing”), J. V. Pickstone (“Establishment and dissent in nineteenth- century medicine”), B. Aspinwall (“Social Catholicism and health”) and L. Barrow (“Anti-establishment healing: spiritualism in Britain”) overturn Thomas’ over-generalized notion of thaumaturgical religion gradually being replaced by science. In its stead we are presented with a view of the cautious coexistence of many types of spiritual and medical healing that became increasingly acrimonious and hostile toward each other in the 19th century for reasons that were as much social and cultural as strictly scientific. The tendency of religtous heterodoxy to gravitate toward non- traditional therapeutic practices and alternate lifestyles IS well-documented. Indirect comparisons between 19th cen- tury medical and religious dissenters and their 20th century counterparts are inescapable.

Two of the four essays dealing wtth Brutish nnsstondr! efforts are especially noteworthy. C. P. Wtlliams chrontcles the slow acceptance of medical mtsstons by ecclesiastical hierarchies as the latter reconceptualized their purpose from a rigidly circumscrtbed evangelism to the spread of LL superior civtlization better represented by the phvsician than the priest. In “Medical Science and Pentecost”. Ranger argues that Anglicanism inherited a coolness toward sptrt- tual enthusiasm from the end of the 17th century onward and that this icy tone ioward mamfestatlons of the Holy Spirit sertously handicapped the Church of England’s ability to compete wtth methodists and Catholics for the hearts and souls of African converts.

In so scholarly and insightful a collectton the final paper by Hexham on religious and spiritual healing in modern America stands out as a major disappointment. Glib and vaguely mysterious in his discussion of groups which he refuses to fully identify. Hexham seems to tllustrate that the historical record is often easier to penetrate than the complex contemporary social sttuatton.

Applied Theolog) Harcard Unirerslr~~ Cambridge. MA. C’.S.A.

ROBERT J. E~ALS

The Origins of General Nursing, by CHRISTOPHER J. MAGGS. Croom Helm, London. 1983. 183 pp. f12.95

While women constitute the maJortty of health workers. most of the literature on the professions concerns male physicians. Recently. however. an interest tn women as health care providers has burgeoned as feminists. in partic- ular. have attempted to close the gaps in our understanding of the past. Such historical efforts reveal the promment role of women in healing occupations, and more generally provide an insight into womens’s roles and relattonships with men in society, and how these have changed over time.

Maggs’ study provides us with a gltmpse of what the tirst generation of general hospital nurses was like. He profiles who this newly trained elite was. why they chose nursing. what their training consisted of, and what the consequences were in terms of nursing practice and the provision of hospital care. Admittedly limited in scope. Maggs (an historian) restricts his analysis to the period of IX8 I to 1914 in England. the period to which modern-day nurstng traces its origins.

Prior to the pertod of interest, nursing was carrtrd out largely by widowed and religious women. although it was generally thought that the ability to nurse was an innate female characteristic. With the raped increase In the number of hospital beds in the late 19th century came a need for additional personnel. However. many nurses working up to this time were unskilled. poorly trained and educated. There were also suspicions (corroborated in contemporary fiction) that at least some of these women were morally disreputable.

Although reformers had hoped to recruit upper-class women to the profession (i.e. those capable of completing the technical training and of outstanding moral rectitude), the women who were attracted to nursing and other “white blouse” work (domesttc service. clerical and commercial work and school-teaching) were. by and large. of working- or lower-middle-class background. Many were young and single, given the informal yet pervasive practice of a “mar- riage bar”. which ensured that a woman would he dismissed from her job upon marriage. The tirst nursing recruits were not, contrary to beliefs prevalent even today, necessarily attracted to the profession because of a “calling” to the work. In fact. for many. the decision to enter nursine was neither a lirst choice career venture. nor something v:ewed as a lifelong vocation. Many of those who chose general nursing as a career vtewed it as a means to achieve various