Book reviews 343

reference to such glaring short circuiting is mentioned in this volume.

The first objective of the book has not been achieved, or rather if it has, we will not know for some years. Lathem poses a problem in his theory that “academic” or Univer- sity reasoning must be the basis for community health de- velopment. In these modern days it is absolutely not necessary for viable ideas to start in the hallowed academic corridors. Academicians are often fascinated more by pedantic persuasions than by practical solutions. Good theory is not necessarily easily translated into action. If community “medicine” is to be responsive to social needs, communities must be involved, or better still, communities must manage their own community health problems. That is politics! A recommendation in this book is to ignore political functionaries. That means little or nothing could be achieved. The second objective assumes that there exists a set of principles of community medicine. Indeed there is, that provided by John Grant. The new set of principles is not really new, leave alone revolutionary. Neither are the principles by Grant really that original if the sociology of Max Weber is taken into consideration. For many of us in the field of community health none of the principles has been hitherto unknown and therefore no rejuvenation is possible. It is further intriguing to note (at the beginning of the book) a definition of community medicine that fails to distinguish the discipline from epidemiology, community health and community preventive medicine.

By and large, however, the community medicine acade- micians in the universities of LDCs, inaudible voices in the wilderness, have little or no reason to celebrate the publi- cation of The Future of Academic Medicine in Developing Countries. The book is neither written by such academi- cians, nor for them and is almost neither for, nor on any particular LDC region. It ignores the realities in LDCs. The book comes after almost a century of health develop- ment in the wrong direction. The very institutions which vehemently pushed for the erection of disease crystal palaces in LDCs are advocating a turn-back to the starting point, a posture bent on a complete dislocation of existing social and health systems. This is nothing short of shock treatment.

Resources required to restructure (community) health in LDCs are progressively diminishing almost proportion- ately to the formulation of new ideas. After generations of colonisation, and continuing neocolonialism, policy makers and their advisors have become increasingly depen- dent on borrowed resources from rich countries, otherwise known as “donor agencies”. These are some of the contra- dictions in the book reportedly meant to be a handy pres- cription to cure the quandary and disarray widespread in community medicine and health in general. The book, therefore, deserves more than cursory reading and evalu- ation. It contains an array of ideas and examples from a wide spectrum, though unrepresentative of world views. The challenges to the western-trained Academic and policy makers are many and concrete, though not altogether novel. A major challenge is to contend with a combination of radical and conservative ideas in the book, -each school of thought has something to worry about in this volume.

Advice on community health from traditionally trained medical doctors has tended to emphasize juggling of hospi- tal beds in rural health facilities. That catch phrase “inter- national standard doctor” is rarely lost to them. If they are able to train doctors, they rarely know how to distribute them. They are unable to produce a doctor that fits in to his/her society as the reference points to in the medical schools such as Hammersmith, St Thomas Hospital. Cor- nell, Boston, to name a few. Concentration on local settings and problems is conspicuously rare, if not al- together absent. In Africa, at least, Universities are western in all aspects. How could they properly lead the rest of the society toward goals other than those of the West? Yet

these universities are the foundations of the change pro- posed in this book. Relevant change cannot be expected soon, if this is the way we have to go.

In some cases, however, LDC governments have used universities to harness their own often conservative ends, medical and other professional schools are excellent examples. Social scientists in the medical schools are often suspect, and Lathem himself does not appear to trust them (p. 172, item 7). It is a vicious circle, the government will not sustain a university that is unresponsive to its demands; the university is eager to exist. Therein lies the problem in this book, whither the university, whither change; or rather more relevantly. whither social change, whither society?

Department of Community Health University of Nairobi Nairobi, Kenya

F. M. MBURU

Nonverbal Behavior: Applications and Cultural Impli- cations, edited by AARON WOLFGANG. Academic Press, New York, 1979. 225 pp. S13.00, E7.80

This book consists of a dozen original essays ‘dealing with a number of different phenomena within the field of non- verbal communication. The papers included are quite diverse. Many consist of summaries of research reported more extensively elsewhere (for example Rosenthal and his associates’ description of the PONS test for sensitivity to nonverbal communication and Argyle’s report of his social skills project), some discuss ways in which pro- fessionals, such as teachers and therapists, can use nonver- bal research in their training and practice (for example, the papers by Waxer and Wolfgang). One paper, Scheflen’s, deals with the methodological and philosophic assump- tions guiding his research. Another by Martha Davis pro- vides a brief history of the field. The quality of the papers in the volume is uneven and they do not really fit together into a coherent whole. Someone wanting a solid basic collection of articles on nonverbal communication will find the selection edited by Shirley Weitz, Nonverbal Communi- cation: Readings with Commentary; 2nd edition, Oxford University Press, a better choice.

There are, however, two outstanding papers in this col- lection which should be read by anyone seriously inter- ested in the way nonverbal communication is relevant to larger processes of social organization. In “Talking Down: Some Cultural Sources of Miscommunication in Interra- cial Interviews”, Frederick Erickson reports that blacks show attentiveness to a speaker differently than whites. A white counselor interprets the signals given by a black stu- dent as signs that he has not understood what is being said. The counselor then recycles what has just been said at a lower level of abstraction, i.e. “talks down” to the black student. For example: “First of all you’re gonna need state certification, state teacher certification, in other words you’re gonna have to be certified to teach in some areas, English or History or whatever happens to be your bag.. .” The effect of all this is that the white counselor not only perceives (mistakenly) that the black student has difficulty understanding what is being said but it shows that the counselor is talking down to him. Though the analysis is confined to a special setting, school counseling interviews, it may well be applicable to many others, in- cluding those medical, and provides a subtle way of cluci- dating some of the conflicts and difficulties that arise in many encounters between blacks and whites.

The article by McDermott and Gospodinoff on “Social Contexts for Ethnic Borders and School Failure” goes far beyond most existing work on nonverbal communication and is among the most interesting and important articles

344 Book reviews

to appear in the field in recent years. Much work on the nonverbal behavior of different ethnic groups has been based on the assumption that problems of communication arise because of cultural differences and can be remedied by sensitizing participants to each other’s culture. Instead of simply accepting this McDermott and Gospodinoff argue that in many cases such differences and apparent “miscommunication” are actively fostered and maintained by the systematic actions of the participants (they note for example that dialect use by black students actually in- creases as they proceed through school). In their paper they examine how the organization of one particular insti- tution, the classroom, leads bright minority students and conscientious teachers to systematically reinforce the bar- riers between them. The subtle analysis developed here, which pays close attention to the details of actual events, poses a strong challenge for future research in the field. It no longer seems adequate to simply list elements of non- verbal behavior that ditfer between cultures. Instead it is necessary to examine in detail the organization of the events and institutions within which such communication occurs. It goes without saying that the type of analysis McDermott and GospodinoIT undertake would be applic- able to many other institutions and might be especially fruitful for medical settings.

The work reeorted in this volume of Erickson. McDer- mott and Gospodinotf, as well as the seminal work of researchers such as Birdwhistell. Kendon and Scheflen, is essentially naturalistic and qualitative. It is therefore dis- turbing to find from Davis’ review of the held that this is precisely the type of work that has difficulty being funded. One hopes that this situation can be changed in the near future since it is this approach that has proved to provide the greatest theoretical and empirical gains.

Deportment oj‘ Anthropology Uniuersiry of South Carolha Columbia. SC. U.S.A.

CHARLES GOODWIY

The Growth of Nursing Home Care, by BURTON DAVID DUNLOP. Lexington Books. Lexington, 1979. 171 pp. 517.95.

It’s taken as virtually axiomatic that the nursing home industry experienced a sudden spurt in growth starting in the mid-sixties, and that Medicare and Medicaid reim- bursement of nursing home care was the prime reason for this growth. Burton Dunlop’s new book. The Growth of Nursing Home Cure, does not, however. hold this truth to be self-evident. Dunlop set about systematically to find out whether there is any factual basis for this heretofore unex- amined assumption. His conclusion? There is none, he says.

Dunlop analyzed census and nursing home data from ten states for the decade 1964-1974, supplemented by a telephone survey of state officials regulating the nursing home industry in an additional thirty-four states. Post- Medicaid (1966) growth of the nursing home industry, it appears, is merely a continuation of a pattern of rapid expansion dating at least from the initiation of government vendor payment programs in the fifties. Furthermore, growth of the industry was even more pronounced in the five years immediately preceding enactment of Medicaid. In fact, the rate of growth actually slowed down in the latter portion of the study decade.

If these Great Society programs did not cause growth. what then was their influence on the industry. Dunlop sees Medicaid/Medicare’s real role as one of ‘shaping’ nursing home care through standards enforcement and reimburse- ment mechanisms. The upshot of this influence is that the nursing homes of today “resemble more the higher-regi- mented, impersonal acute care hospital than the more

family like residential settings of a decade or two ago”. In developing this thesis Dunlop provides the reader with a thorough history of government involvement in nursing home care and discusses possible future trends in long term care.

Over the study decade (1964-1974) the number of nurs- ing home beds rose 119% in the ten sample states. and number of beds per 100 elderly grew 73%. But if, as is commonly supposed, Medicaid and Medicare were not the ‘prime movers’ in the growth of the nursing homes. what factors did contribute to this growth? Dunlop examines factors relating to sociodemographic changes, health care institutional developments, and developments in the regu- lation of the nursing home industry.

In analysis of 1960-1970 census data, Dunlop found sig- nificant correlations of three sociodemographic factors and the increase in utilization of nursing home beds. These variables relate to change in percentage of elderly popula- tion age 85 and over; change in proportion of elderly living independently; and change in percentage of non-elderly females participating in the labor force. The correlations. while not conclusive, point to changes in family structure as contributory to nursing home growth.

Providing quantitative confirmation of the impact of mental hospital deinstitutionalization on the growth of nursing home care, Dunlop’s analysis of census data shows an increase of 69% in the proportion of elderly in nurs- ing homes for 1960-1970 and a decrease of 487: of elderly in mental hospitals during the same years. Discharging the elderly mentally ill from mental hospitals had a profound effect on the growth of nursing homes-an effect supple- mented by the allied practice of diverting to nursing homes those patients who would have been admitted to mental hospitals.

The most important aspect of this book is its thorough presentation and analysis of the influence of government policy, particularly the enforcement of standards, on the evolution of the modern nursing home industry. Dunlop finds the initiation of payments by state welfare agencies directly to vendors of service instead of cash to recipients and broadening of eligibility criteria, as contributory to nursing home growth.

Dunlop’s analysis of the effect of standards enforcement is particularly perceptive. He relates the history of the de- velopment of construction standards through the Hill-Bur- ton Program and the subsequent Medicare/Medicaid adoption of the Life Safety Code which he calls “the most far reaching and certainly the most directly visible com- ponent in the transformation of the industry”. He shows how the enforcement of Hi&Burton standards and the Life Safety Code encouraged the building of large institutional nursing homes to replace smaller converted dwellings.

Not neglecting the more subtle effects of government standards enforcement, Dunlop points out the enhance- ment of the public image of the nursing home under Medi- care and Medicaid-how Medicare as an earned benefits program removed the welfare stigma formerly associated with government vendor payments to nursing homes under the Old Age Assistance program. Standards enforcement not only fostered the development of the medical model of care for the elderly, Dunlop contends, but led to the increasing acceptance and legitimacy of nursing homes in the medical care system.

Dunlop also demonstrates how one public policy can complicate or even frustrate another. The “chronic excess demand for publicly subsidized beds” is his case in point. Broadening program eligibility has been one goal, Yet con- trol of numbers of beds is another goal of considerable importance. Add the third goal of effective enforcement of standards for patient care and physical plant, and serious goal conflicts arise. The shortage of beds has impaired the ability of government agencies to enforce standards, for agencies are reluctant to close existing facilities and further