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

570 Book Reviews

geography of three regions, borrowing on the themes ex- plored in earlier chapters. The regions and themes covered are: the problems facing Africa's most populous nation Nigeria; the social and political impact of apartheid and the implications of its long-awaited demise in South Africa; and the front-line states of Southern Africa which are having to adapt to a neighbour which has changed from being auto- cratic and militaristically ruthless to being an independent, democratic and economic giant.

The material is presented in a methodical way, with a good production value, a pleasant font, and the use of numerous case vignettes, figures, tables and photographs. The case vignettes, in particular, serve to illustrate general points with specific examples derived from a range of sub- Saharan nations. For example, in the chapter on Mineral and Energy Resources, the vignette on Botswana shows how the development of a highly profitable mining industry does not necessarily lead to social development on a national scale. Or, while discussing Ideology and Economic Develop- ment, the vignette on Mozambique shows how no matter what the ideology of the ruling government (Marxist in the case of post-independence Mozambique), external forces may undermine the entire structure of government and development.

It is important to point out some of the potential weak- nesses of this book. As with any such text, some chapters of the book may already be outdated, most notably the chapter on the political economy of Nigeria which fails to

mention the current crises involving the nexus of multi- national industry, environmental pollution, indigenous peoples' social welfare and human rights. While the author ascribes, quite justifiably, many of Africa's contemporary problems to its colonial legacy, the IMF and other neo- colonialistic interferences from non-African societies, there seems a reluctance to evaluate the role of the African ruling class and elite and the betrayal by many erstwhile leaders of freedom movements to the cause of social development and justice. A number of minor typographical errors do not detract from the overall impressive presentation although some factual errors are unfortunate, such as the point that the new name of Zaire is Congo-Kinshasa (p. 19). In attempting to cover such a large area lies its most obvious weakness: the sense that some of the issues are covered superficially and incompletely. However, as the author has pointed out, this is meant to be an introductory text, an overview for a wider readership, and in this regard the book is wholly recommended. Rather than stressing the simi- larities and generalizations (so often a problem with texts aiming to describe Africa), it draws on the rich diversity of African peoples, cultures and societies to produce a very readable, informative and entertaining book.

Institute of Psychiatry De Crespigny Park London, SE5 8AF U.K.

Vikram Patel

Equal Partners: A Physician's Call for a New Spirit of Medicine, by Jody Heymann. Little, Brown and Company, Boston, MA, 1995. 257 pp., U.S. $22.95.

First as a patient, then as a physician, I have observed the responses that accompany the entrance of chronic disease into patients' lives. Most patients resign themselves to illness, scaling back expectations and becoming passive actors. Others are devastated by debility, allowing disease to loosen their hold on the social world with divorce, unem- ployment and even suicide the results. But some patients, like .Iody Heymaun, adapt to disease, finding motivation to change their lives through insight discovered in illness.

Equal Partners: A Physician's Call for a New Spirit of Medicine recounts Heymann's experience with a cerebral arteriovenous malformation. Her story is a poignant ex- pression of motivation and insight. From her experiences she supplies an answer to the question of why passive resignation and debilitating detachments are common re- spouses to illness. The health care system, by disenfranchis- ing and subordinating patients, unnecessarily maximizes many of the adverse consequences of illness on patients' lives. Heymann's solution is to place patients and physicians on an equal footing so that patients can be partners in their own medical care.

Heymann's life as a patient, as well as her dissatisfaction with physicians, began with a seizure occurring shortly after her graduation from medical school. She describes in harsh detail the callousness and poor treatment that follow as she is diagnosed and operated on for an arteriovenous malfor- marion, an unusual and dangerous collection of blood vessels in her brain. Her disappointment from the patient's viewpoint is palpable, but is sharpened by her physician's knowledge that so many problems were avoidable. In her experience, the medical profession appears to be more of a hindrance than a help.

From the beginning, Heymann is struck by the unques- tioned assumptions that could have been easily set straight by honest communication. She recounts the emergency medical technicians' assumption that her seizure was related

to drug abuse and, later, after her surgery, the belief that her pain medications were adequate despite her continued complaints of pain. The same lack of communication characterizes other aspects of her experience, including the side effects of medications, the lack of coordination by different specialists and, particularly, expectations about recovery. Difficulties faced by patients after leaving the hospital, Heymann asserts, cannot be underestimated from the patient's perspective. This element of health care, how- ever, is often dismissed and misunderstood by physicians. Only after returning home do patients face the task of reintegrating themselves into social relationships, including new compromises around family and work roles.

Expectations from both herself and others weigh heavily on Heymann during this experience. Prior to her life as a patient, she appears well-poised at the age of 29 to coordi- nate the combined roles of wife, mother of a 10-month-old and intern in a demanding pediatric residency. In adjusting to brain surgery, recurrent seizures and anticonvulsant medication side effects, she describes the constant tension between reality and her expectations, an issue that her physicians appear not to appreciate. She builds a strong argument for narrowing the distance that separates patients and physicians. Without the repugnant effect of subordina- tion, the true needs of patients are more likely to be fulfilled. Beyond simply criticizing the current system, Heymaun outlines several policy initiatives to ameliorate these problems, including revitalizing the informed consent process, making the doctor-patient relationship central to medical education, and improving access to health c a r e .

Despite my identification with Heymann's chronicle, occasionally it is clear that she was a physician before becoming a patient. Her discussion of patient "compliance," for example, tacitly accepts a model that equates noncom- pliance with patient failure. Recasting this issue as one of "adherence" would be more than a semantic gesture towards consistency with her general themes. In her discussion of managed care, Heymann, like many physicians, appears to idealize American medicine's