Book Reviews 1653

Morir de Alcohol. Saber y Hegemonia Medica, by EDUARDO MENENDEZ. Alianza Editorial Mexicana, Mexico D.F., 1990. 277 pp.

This book is an anthropological contribution to a topic of medical interest which, by its very existence, questions the fact that it should be of primary interest to medicine. Drawing a distinction between alcoholism-as a medical entity-and alcoholisation (or alcoholic behaviour) as a societary process, the author presents a highly readable discussion on the production of scientific knowledge and on the means and ways by which a certain model (in this case, the medical) becomes hegemonic. In this sense, the book can be considered a case study on the relationships between medicine as a profession and the social sciences.

is a process which creates the objects about which to speak.” It should be added that the essential point here is power, and professional dominance is an established cliche in discus- sions about medicine and health. Curiously enough, this wisdom has become more of a standard knowledge than of a partisan argument, the inadequate response from the medical establishment notwithstanding. A discourse is a locus of articulation between expressive means (languages) and social interests, and all disciplines may be regarded as discourses in this sense. The process of medicalisation and of professionalisation of medicine can be viewed as the constitution of an hegemonic discourse.

Perhaps the most simple way of contrasting the medical and the anthropological views is to compare the conse- quences of a certain disease called alcoholism with the social functions of alcoholisation. Ritual drinking behaviour, or for that matter, any alteration of consciousness is then considered in a wider context, leading to a “destigmatisa- tion” of the behaviour. Instead of defining the problem only in medical terms, what is called for is a consideration of its social functions and implications. Insofar as this may in- volve different courses of action to fight the consequences or to prevent the ills, a detailed discussion of self-help organiz- ations (Alcoholics Anonymous being one of the best examples) in their dialogue with academic medicine can be highly illuminating. For the busy practitioner confronted with a problem only partially amenable to an exclusively medical formulation and who is frustrated by the results of his/her actions, it is refreshing to get a critical view of such highly respected entities as ‘primary care’ or ‘medical tech- nology.’

The book deals extensively with the Mexican case, and the ways in which the medical system in Mexico has accepted the challenge of dealing with alcoholism. This part of the book will certainly be of interest to the methodologically minded reader, then it is only by way of example that the main points can be illustrated. It is particularly relevant to workers in the health field in Latin America, since many of the points raised by the Mexican experience find counter- parts in other countries of the region. To take just one example, the definition of dependence, exclusively in indi- vidual-biological terms and not, as Menendez suggests, as a social factor, may be a hindrance to adequate handling and prevention in countries such as Chile, where “alcoholic subcultures” and their attendant rituals have long been recognised among the difficulties for medical action. They seem to show, however, that strategies dealing with the social dimension should be pursued.

This book should be regarded as a valuable contribution to the dialogue at the interface between the social sciences and medicine and deserves extensive discussion and critique.

Although the hegemonic status of a conventional medical Psychiatric Clinic model is critically considered, this is not a radical book. It Unit~ersity of Chile is a book which argues from the position that “a discourse Santiago, Chile

FERNANM) LOLAS

Remunerating General Practitioners in Western Europe, by PETER P. GROENEWEGEN, JOUKE VAN DER ZEE and F&NB VAN HAAFTEN. Avebury, Aldershot, England, 1991. I25 pp., f25.

Presumably stimulated by the search for measures to achieve the generally perceived necessity to contain ever increasing health care costs, the last two decades have seen an increas- ing number of studies comparing health care systems across countries. This book is different because it focuses on the role of an important health care professional in many countries, i.e. the general practitioner. The aim of the book is to provide information on the income position of general practitioners in eleven Western European countries and to analyze relations between the position of general prac- titioners within the health care system and their incomes. For all countries the same reference year, 1985, was chosen.

The book is divided into two parts. The first part, after introductory sections, compares the position of general practitioners in the eleven countries studied according to various characteristics. These include the competitive pos- ition of general practitioners (e.g. entry barriers to the profession and list sizes), the services they provide, the way they are remunerated, the access of patients to specialist care, and an estimate of average general practitioner income after subtraction of practice costs and before tax. In all these aspects there are substantial differences between the various countries. General practitioners in Germany and The Netherlands appear to be best off in terms of income (before tax) while their colleagues in Belgium and Italy are worst off. Interestingly, the entrance of students into medical schools is not restricted in the latter countries and hardly any

post-graduate training is needed for becoming a general practitioner. Combining these findings with the absence of restrictions on the number of practising general prac- titioners in Germany, one may expect a flow of students to Belgium and Italy as well as a flow of general practitioners to Germany. Indeed recently substantial numbers of Dutch students have entered Belgian medical schools.

The book continues with an explorative analysis of relations between several aspects of the position of general practitioners and their income. Based on this analysis some tentative conclusions are drawn. Average income of general practitioners appears to be lower in countries where they serve a smaller population, though the latter does not result in fewer hours worked per week. A possible relation with quality of care is speculated upon. Furthermore, a positive relation is found between the range of services provided by general practitioners and their average income. Payment systems that combine capitation and fee-for-service are in the top of the income rank-order. Finally, direct access to specialist and/or hospital care is not correlated with income. It seems to me, that the information given in the book supports the hypothesis that health care expenditure (as a percentage of GDP) is in general higher in countries with direct access to specialist and/or hospital care.

I was surprised to read on p. 29 that “the intended health care reform in The Netherlands (. .) proposes a remunera- tion system more or less comparable to the Danish one” (this entails a mix of capitation and separate fees for consultations and specific services). To my knowledge the proposals of the Dutch government for a drastic reform of the structure and financing of the health care system neither

I654 Book Reviews

explicitly endorse this type of remuneration of general practitioners nor preclude it.

Because of the enormous differences between countries, these conclusions should be considered tentative, as the authors themselves implicitly note by calling their analysis explorative. The analysis once again shows the difficulties one encounters when comparing health care systems of different countries in some detail. Each health care system has its own idiosyncrasies imbedded in the national culture and rooted in history, and thereby making quantitative analysis of aspects of these systems across countries rather hazardous.

The second part of the book contains detailed infor- mation on the position of general practitioners in the various countries, preceded by short descriptions of the respective health care systems. These country studies provide the information necessary for the explorative analyses in the first part. Though I am not a connoisseur on health care systems outside The Netherlands, I noticed a few errors in the description of some countries, the most important of these is the amazingly high copayment rates for France. For this country the book reports copayments of, for instance “75% of the agreed fees for genera1 practitioners and dentists” and “80% of the costs of hospital treatment during the first thirty days of hospital stay” (p. 76). Consultation of another publication on this subject revealed that these are not the copayment rates paid by the patients but the reimbursement rates paid by the insurance schemes. The country studies are of interest

because, for one thing, they show the remarkable variety in health care systems. some of the problems and solutions and thereby may provide ideas that policymakers and re- searchers from other countries could build upon.

Because of the problems with cross country analyses, this study seems stronger in its descriptive contents than in the analytic component. Its value would certainly have in- creased if a more recent reference year (which now is 1985) had been used, especially in view of the major changes that have been initiated in the last few years m many countries, e.g. The Netherlands, the U.K. and Sweden. Some recent developments and intended changes are mentioned in the book. Furthermore it is a pity that only 7 out of the I2 EC member states are included in the study. Coverage of all states is important because of the (in)famous year ‘1992’- which actually implies I January l993-as of which date free movement of persons. goods, capital and services will be possible between the member states. This could increase cross boarder provision of health services.

Despite the caveats mentioned above, this study is a useful reference book on the subject and perhaps a starting point for further reading.

Department of Health Poliq and Management

School of Medicine and Health Sciences

Erasmus Uniaersiry, Rotterdam The Netherlattd.s

REI*‘~ VAN VLIET