568 Book Reviews

aware of the limitations of an ultra-specialist approach to science.

Another impression which emerges from the reading of the book is how lively and current this discipline is. People not well acquainted with ethnomedicine may consider it the archaeology of medicine, a set of dated rituals and traditions handed down from generation to generation, which in- evitably are going to disappear. This is not the case. All the ten essays, one way or the other, provide evidence for the constant evolution of ethnomedicine. Across different cul- tures and throughout the ages people have always tried to interpret new health threats and formulate new healing procedures for any factor or change which destabilises their physical and mental equilibrium. It is interesting to read how in rural Jamaica, traditional models of ethnophysiology are utilised as a plausible explanation for the risk of acquiring AIDS. Another essay reports on a series of lectures by an aged practitioner of Ayurveda from Tamil Nadu, South India. The practitioner presents an Ayurvedic interpretation of cancer, based on the theory of humoral balance within the body, although cancer in India is con- sidered a Western disease and there is no independent description of its causes and mechanisms in the two thousand-ycar-old Indian medical tradition. An even more giobal perspective is tackled in a discursive study of Tibetan history which describes how Lamaism absorbed and accom- modated shamanic and Tantric practices following the rise of Buddhism with its dramatic effects in redefining the concept of self in medical practices and how Amchi medicine combined the practical medical theories of Ayurveda with the Tibetan variant of Buddhism.

More recent and rapid changes, like the socio-economic transformation of societies in transition, are becoming increasingly familiar in present ethnographic literature. New healing techniques are emerging following the state of malaise typical of poor people caught between an old order, based on gift and exchange, to a new society more market oriented. An essay reporting on traditional and present treatment techniques in Rwanda clearly emphasises how healers adapt themselves in an attempt to resolve the psycho-social contradiction associated with accumulating wealth in a society which has traditionally emphasised the conversion of wealth into social relationships through the giving of gifts. As the editor comments: "An illness experi- enced by one person is often a sign of a problem experienced in a larger social body" (Nichter, p. 236). The role of the

economic context as a key factor of individual health also emerges in other essays from different continents. In a case study from North Coastal Peru, the author focuses on the interrelationship among physical, economic and social health, showing how experience of illness and its traditional management cannot be fully understood unless the economic structure of the society is taken into account. Similarly, a study on Malay traditional medicine implies that socio-economic and political changes influenced the transformation of the healing traditions from sociocentric to individual centred.

Furthermore, the book offers helpful information to anyone involved in the study of ethnomedicine. Besides the presentation of a number of well-designed studies, based on different theoretical and methodological approaches, the first two essays of the book discuss methodological issues. One reviews different epidemiological approaches to evalu- ate the efficacy of traditional health care practice and calls for greater empirical rigour in the study of ethnomedicine. The other presents the author's attempt to estimate the illness burden of a folk illness, Empacho, by age and gender in Guatemala as an example of systematic data collection. Mark Nichter's commentary successfully guides the reader in the multiple methodological and theoretical orientations of current ethnomedical research.

The interest in this book goes beyond its primary audience of anthropologists and ethnomedicine researchers. Anyone working in public health, especially those in developing countries, may get ideas and information not just interest- ing, but also useful to orient themselves in a new cultural environment. The importance of the practitioner-patient relationship, the search for a consensus on the therapeutic approach, the perception of disease and health seeking behaviours of ill people, the effect of cultural changes during a period of transition are concepts losing importance for the medical practice in a Western homogeneous context while they remain a key to define successful therapeutic strategies in non-industrialised societies. In conclusion, this is an excellent book for anyone involved in ethnomedical re- search; at the same time, it is valuable help for public health professionals trained in the West who are serving, or willing to serve, in different cultural settings.

Dir. Gen. for Development Cooperation Italian Embassy, Cairo Egypt

Filippo Curtale

Facts and Research in Gerontology 1994: Epidemiology and Aging, edited by B. J. Vellas, J. L. Albarede and P. J. Garry. Serdi Publisher, Paris, 1994. 300pp. $44.95.

This book is the sixth of a series first published in 1992. It consists of 25 original articles either reviewing or describing recent research findings, nearly all from North America or Europe. In the opening chapter Kane discusses nomencla- ture. Most of the topics belong to clinical epidemiology, defined as the study of factors associated with outcome of diseases once they have occurred rather than, as in epidemi- ology, with the causes and distribution of disease in a population. Gerontology is the study of aging, but the focus here is mainly on disease. This review may give some idea of the range of topics covered in this volume.

Aging and cognition is the topic in two longitudinal studies. One investigates how subject attrition affects the interpretation of findings (Rabbitt): this depends on whether withdrawal is due to death or poor health, or to external circumstances or personal choice. In the other study, Poitrenaud, from the Centre Gerontologie Claude Bernard,

Paris, examines the sources of individual variation in cognitive aging in a group of elderly 'men in full-time managerial posts. Over a 14-year period, mean scores on all the tests fell. Cardiovascular disease, years of education and physical activity were shown to be independently predictive (sociocultural interests, alcohol consumption and use of hypno-sedative drugs were not, in this sample). Regarding education, the authors conclude that the knowledge and skills acquired during school years may help to maintain high levels of cognitive performance decades later.

Elder abuse is probably common but until recently re- ceived little notice; dementia is a risk factor, particularly when the elder has himself been aggressive. In a review of mortality following hip fracture at the Mayo Clinic, Rochester, Poor reports that dementia is a risk factor both for fracture and for outcome; a comprehensive programme to minimise mortality is outlined.

At the other end of the scale is the 'problem' of successful aging. This is discussed by Seeman, from the Yale University School of Medicine, in the context of quality- adjusted life expectancy, and the compression of morbidity

Book Reviews 569

hypothesis. The hope is that the prevalence of successful aging can be raised by policies and interventions to realise the potential for this in the general population.

A study from the Tokyo Metropolitan Institute of Geron- tology (Shibata) contrasts the experience of two groups of elderly persons, one living in a mild, stable climate, the other in a climate changing from extreme heat to winter snow. The former individuals fared better over a two-year period. This may have been due to the social, cultural and po,-ibly dietary differences associated with the climatic differences. In a painstaking comparison of dietary intake, subjective health and functional level in successfully aging persons and others living in Toulouse, France 0/elias), the potential value of examining functional activity in relation to diet is pointed out.

Several studies are concerned with the subjective judge- ments of elderly patients. Subjective health status predicts mortality but the mechanism has been much debated. Analysis of the data in the American Longitudinal Study on Aging showed that this relationship no longer held after the introduction into the model of a measure of deteriorating functional status 0Volinsky). This supports the hypothesis that elderly subjects' assessments of their health are ex- pressions of their awareness of their 'health trajectories' and their expectation of personal survival. Patients' satisfaction with their treatment following stroke is reported using the London Stroke Satisfaction Questionnaire. This is easy to administer and complements objective measures. Another questionnaire is available for assessing bowel symptoms.

Many old people are extremely frail and inactive. Shephard, from the Department of Preventive Medicine and Biostatistics, University of Toronto, concludes that exer- cising may be beneficial even in the very old: it may decrease dependency, reduce anxiety or depression, and check the course of osteoporosis. Continued activity may prolong life and, in particular, improve its quality.

Cancer is the subject of three articles, on breast and prostatic cancer, and one reviewing the relationship between cancer and age (Balducci); a recent increased incidence of lymphomas and brain tumours in elderly persons is unex- plained. The genetic basis of some breast cancers is now well established as is the role of post-menopausal oestrogen. Primary prevention may be best achieved through chemo- prevention, e.g. by oestrogen antagonists. Apart from age, the risk factors for prostatic cancer remain obscure; it occurs worldwide but familial clustering suggests a genetic basis.

The remaining chapters are on rehabilitation, health care costs of diabetes mellitus, the elderly at risk, advance directives and the physician as director of an interdisci- plinary service. There are reports from several countries about their geriatric services or research programmes. Tideiksaar, from the Mount Sinai Medical Center, U.S.A., gives an account of fascinating work on the development of strains of transgenic mice to test the hypotheses that free radicals and/or the hormone vasopressin are involved in aging and disease, and on the role of proteogiycans in amyloidosis and Alzheimer's disease. More basic science is also represented in reports of a decline of immunorespon- siveness in polymorphonuclear cells with age (Antonaci), and of age-related changes in lymphocytic mitochondria associated with smoking, overweight and cholesterol levels (Regius, Hungary), both of which would impair the immune system.

This book offers the reader a wide view of current research, from which he or she can select what is of personal interest. Individually the chapters are of a good standard, although they differ so much in subject matter that it is hard to discern a common theme.

Department of Psychiatry University of Newcastle upon Tyne U.K.

David Kay

Africa South of the Sahara: A Geographical Inte~retation, by Robert Stock. Guilford Publications, New York, 1995. 435 pp., U.S. $45 (cloth).

This timely book sets out with a broad agenda to describe and analyse "the sociocultural, political, and economic processes that help explain the patterns of human utilization of the continent and its resources and the dynamics of change in Africa's geography". In doing so, it extends the contexts of geography to include history, demographics, economics and politics. As a general introduction to a vast and hugely complex subject, it is a thoughtful and analytical book which would be of interest not only to geographers, but to any social scientist with an interest in an analysis of contemporary Africa from multiple historical and political standpoints.

After an Overview which describes the physical and political geography of the area, the book moves to the historical perspective essential to understand contemporary Africa providing a succinct account from prehistoric times through the colonial period up to independent Africa. The next section examines the population dynamics of the continent, for example, describing the migrations of people due to war or economic circumstances, the uneven distri- butions of population and its environmental impact and the causes behind the rapid growth in population which threatens to outstrip economic development. A section on Rural Economies is a refreshing reminder that the majority of Africans are rural inhabitants and covers topics such as indigenous food production and the looming food crises. Urban Economies recognizes the inexorable rural-urban

migration which is changing the face of African society and delves into the problems facing the urban populations, especially housing. Social Pohcy examines the role of women and development, and the development and changes in education and health policies in Africa. The latter was of particular interest to this reviewer; a broad range of current issues ranging from the debates on the relevance of Western style medical education to the impact of imposing user fees in public health facilities are described clearly and form a coherent part of the overall theme of the book. The next section describes three fundamental resources which Africa has in plenty; mineral and energy, fauna, and vegetation. Difficult issues relating to the ownership of the mining industry and distribution of its profits; the lack of develop- ment of Africa's hydroelectric potential at odds with the possible environmental impact of such development; and the varying views on the ivory trade from East and Southern Africa are covered. The section on African Economies describes economic development at three levels: Africa within the world economy where its marginal and vulnerable position is examined, pointing at factors such as the depen- dence of primary product exports; the relationship between ideology and development compares capitalist, populist socialist and Afro-Marxist forms of government in indepen- dent Africa; and finally, the focus shifts to grassroot econ- omic development with its emphasis on "serf-reliance" which the author points out threatens to become an excuse for African governments and development agencies to absolve themselves of responsibility for local development. The final section, and arguably the most important new contribution in this book, is an analysis of the political