Book Reviews 1341

In view of such similarities it should, in principle, be possible to formulate generally applicable methods of pri- mary and secondary prevention; in other words, to tackle the critical question--what is to be done. The second section makes a concerted effort in this direction. All chapters emphasize the need for preventive intervention and social- psychological treatment of the victims; some chapters make specific recommendations concerning psychological and so- cial-environmental interventions that might have either a protective and ameliorative or a harmful effect, and many emphasize the social context in which the disaster occurs and the ability of the community to provide social supports as important co-determinants of the short and long term consequences of the traumatic experience. Unfortunately, little empirical evidence is presented which would make it possible to distinguish between interventions that are likely to be helpful and those with the potential for doing more harm than good. This gap in knowledge probably reflects the generic difficulty of conducting epidemiologically valid studies which could compare and contrast the efficacy of alternative methods of intervention. Yet, even the most sophisticated investigations on the effects of trauma are likely to remain academic exercises without such assessment studies.

Hertofsen's report on the reactions of NATO troops who were buried in an avalanche in Norway is an important exception. It tests the hypothesis and presents empirical

findings that demonstrate the critical importance of group cohesion before, during and after a disaster as factors that protect the victims against long term psychiatric disabili- ties. In principle, a more detailed analysis of the social variables that promote and maintain such group cohesion under various conditions of stress, such as, for example, the role of a shared implicit ideology, should therefore provide the base line data for planning generally applicable interventions.

Another possible limitation of the reports is that nearly all investigators document in detail the frequency of negative psychological effects following a disaster. Yet, the multiple developmental, social and psychological factors that pro- mote resilience in the face of trauma are not examined in any detail. Such information might also provide essential clues about effective strategies of preventive intervention and rehabilitation. These limitations notwithstanding, the vol- ume is an invaluable source of carefully documented empir- ical information about the universal psychological reactions to trauma and disaster. By highlighting major gaps in our knowledge, it also identifies critical issues that require further research before the available information can be applied in a clinical-social context.

Harvard Medical School The Children's Hospital Boston, MA 02115, U.S.A.

Peter H. Wolff

Flexible Bodies: Tracldng In~gnif f in American Culture-- from the Days of Pofio to the Age of AIDS, by Emily Martin. Beacon Press, Boston, 1994, 352 pp. ISBN 0-8070-4626-4, U.S.$25.00 (cloth).

When flexibility emerged as the central concept in anthro- pologist Emily Martin's study of cultural beliefs about the human immune system, the author wondered if this were linked to flexibility as it is valued in late 20th-century capitalism and politics. To find this out, Martin and a group of graduate student assistants became participant-observers in immunology laboratories, took science courses in immunology and microbiology, became involved in neigh- borhood groups and businesses throughout the Baltimore area, and joined both AIDS service groups and AIDS political activist groups. They interviewed over 200 individuals--scientists, physicians, laboratory technicians, alternative healing practitioners, hairdressers, community organizers, welfare recipients, architects, high school stu- dents and others from all walks of life, asking about how these individuals perceived of their immune systems. Martin's book Flexible Bodies: Tracking Immunity in American Culture--from the Days of Polio to the Age of AIDS is both a collection of the views she received from those she interviewed as well as an attempt to link private ideology about health, illness and the body to broader societal values.

The book's title may suggest more of an historical overview than is actually provided, but Martin's concise discussion of beliefs about health and illness as influenced by polio epidemics in the 1940s and 1950s serves well to place the views about health, illness and the body that she collected from the hundreds of interviews conducted forty years later in various Baltimore neighborhoods. Martin reminds the reader that it is only after the introduction of gamma globulin in 1954 and the Salk polio vaccine in 1955 that the word 'antibody' gains currency in wider society. It is in the late 1950s that Americans are openly introduced to their immune system, but it is in the 1980s that the

recognition of AIDS propelled the immune system to the very center of our culture's conception of health.

Over the decades the most enduring vision of the human immune system had been one of an army of white blood cells fighting off germs in defense of the body as nation-state. Martin thoroughly investigates the use of military imagery to describe how the body protects itself from disease, looking at many examples from the mass media. She makes interesting observations about the use of violent imagery to describe the immune system, but, as the author herself admits, she is less convincing when she tackles the roles of race and gender in this metaphor.

Interestingly, a major aspect of the military metaphor has been the belief that the immune system maintains a clear boundary between self and non-self, mercilessly annihilating the non-self as a foreign and hostile invader. More recent studies, however, show this view may be too simplistic. The immune system may only see in the form of 'internal images', that is, all possible varieties of the foreign have been conceived in advance and the immune system only sees and knows itself. If the immune system does not 'recognize' the intruder, it cannot mount a defense. With such new infor- mation coming forth, a few scientists as well as nonscientists are advancing different metaphors to describe the immune system and developing a new sensibility about how the body relates to its world. One alternative metaphor that catches Martin's attention is that of a regulatory-communications network.

Images of communications systems and complex systems play a large role in Martin's study. The author notes that many scientists, alternative practitioners and nonscientists are looking at the body and the immune system as a series of interacting systems that are constantly changing. It is out of discussions of the complex systems metaphor that the concept of 'flexibility' emerges. The century-old 'lock and key' metaphor for describing the Y-shaped antibody's attack of an antigen gives way to the idea of the antibody's flexible 'socket' that has some leeway in connecting to the intruder and possibly disease-inducing germ in order to

1342 Book Reviews

destroy it. This flexibility within antibodies is then related to such descriptions of the late-20th century capitalist economy as "flexible specialization" and "flexible production." The human immune system is linked to Total Quality Management where the valuable employee is the flexible worker.

What is implied about one's sense of self when a systems model is applied to the body and health? Martin describes the main features of the complex systems model, concentrat- ing on how complex systems can suddenly shift from one part to another, and on how small initial causes can have large effects. So what happens when the system breaks down? Martin's paradigm for immune system breakdown is, of course, AIDS. At one point Martin highlights the "com- plex systems" model as applied to the immune system by addressing a particularly shocking (and newsworthy) pres- entation at the Eighth International AIDS Conference in Amsterdam in 1992. With the announcement that doctors had treated thirty AIDS patients who showed no trace of HIV in their bodies, confidence in the one-cause theory of AIDS was shaken. Was AIDS a result of many immunosup- pressive agents of which HIV was only one? Martin's understanding of complex system laws comes into play as the constant instability of a body in which "all is in flux, order is transient, nothing is independent, everything relates to everything else, and no one subsystem is ever necessarily in charge" (p. 250).

Martin discusses the primacy of vision in the creation of scientific knowledge about the immune system, and one of the most interesting aspects of Martin's study is her analysis of scientific visual images and the role images play in disseminating information. While taking science courses and working in science laboratories, Martin learned how scien- tists use pictures to secure an argument, as conclusive visual evidence of claims. As part of her project, Martin went out into Baltimore neighborhoods and showed a variety of people a scientist's image, an electron micrograph of im- mune cells at work. She stated three motives for doing this: (1) to see how familiar people were with these images "perambulating out from science," (2) to see if people would speak "imaginatively" about these images produced by rational science and (3) to see how such images might change the way a person thought about his or her body. The first and third motives would seem to yield immensely valuable information. (The potential gains for pursuing the second motive remain less clear to me.)

The reactions to the micrograph were astonishing and revealed major differences between how scientists and non- scientists viewed disease and the body. Some nonscientists almost refu,u~l to believe that these pictures really showed the body's interior. One of the interviewees, an accountant, claimed that "there's no connection between . . . me being a conscious human being and this cell that's inside me" (p. 178). Considering the social realities of poverty and illness, a community organizer asserted that the electron micrograph was "really interesting, but--not important at all" (13. 180). As the reader takes in the different rejections of the scientist's micrograph by nonscientists, it is interesting

to note that, in turn, only five out of the forty scientists Martin interviewed said they made connections b e t w ~ the research they carried out in the laboratory and their own health.

In the end, Martin warns about potential problems with new metaphors and paradigms that may allow ideas about the immune system to support a new social Darwinism. She is disturbed that the insistence on such flexibility will turn into a new form of repression in which the immune system will play a huge role in how individuals arc valued. Adver- tising bears this out when Martin notes that a SAAB chassis is touted as "the antibody for the auto accident" (p. 184). Vaccines have their role as educators of the immune system, so science must march on making its important discoveries. For our health, we will continue to provide science with the resources it needs to keep our immune system as 'educated' and as highly evolved as possible. As she probes through various cultural spaces, Martin sees where such beliefs can potentially discriminate against certain individuals and groups.

Pertinent examples of how the immune system, human value and discrimination can converge are found in stories shaped by intellectual endeavor. Martin retells a few of these stories at the beginning of her final chapter to demonstrate this view of the "survival of the fittest immune system." One striking historical account she cites is the work of a scholar publishing in the popular journal Discover. This historian explains disease as the European colonialists' greatest weapon. Smallpox, measles, typhus, pertussis and yellow fever decimated the Native American population when Europeans invaded the Americas, but why didn't diseases indigenous to the Americas kill off Europeans? Martin's historian claims that the Europeans' long history of trade with various cultures in Africa, India, and China had brought Europeans in contact with a vast miscellany of potent germs, and thus their immune systems were more highly 'educated' than those of the Native Americans. One can see, and Martin does, the opportunities for supporting discrimination here.

In Flexible Bodies Martin furthers our understanding of the ideological relationships between individuals' private views of the human immune system and various spaces within the public sphere, such as science, government, business and academia. At the beginning of her book Martin evocatively describes these connections as "implosions, places where different elements of the system come into energetic contact and collapse in on themselves" (p. 11). By making the rounds of neighborhood clubs and services, science courses, and science laboratories, Martin has pro- duced a meaningful view of multiple experiences that gives us more evidence on how intensely interconnected beliefs about health, illness and the body are to the diverse realms of everyday life.

Genome Ethics Committee~Project University of MichiganAnn Arbor M1 48109 U.S.A.

Nancy Anderson