Book Review

Cancer in the Community: Class and Medical Authority

N Engl J Med 1994; 330:444-445February 10, 1994

Article

Cancer in the Community: Class and Medical Authority
By Martha Balshem. 174 pp., illustrated. Washington, D.C., Smithsonian Institution Press, 1993. $42 (cloth); $15.95 (paper). ISBN: 1-56098-250-0 (cloth)

The tapestry of American society is woven from many interdependent yet distinct cultural threads. Each cultural perspective is characterized by beliefs and values that influence the interpretation of events. Given the broad spectrum of values and beliefs in this country, there is a potential for misunderstanding and poor communication among persons, groups, and communities when cultural differences are not taken into account. Through an examination of the beliefs of “the working class and medical authority” in the area of health, Cancer in the Community elaborates on the problems that arise when there is a discontinuity of belief between groups working together.

This book, a welcome addition to the literature on public health, health education, and psychosocial oncology, examines the promotion of health and appropriate avenues for the delivery of services to persons, groups, and communities. It is easy to read, well organized, attractive, and intellectually accessible. The author covers an enormous territory: problems in the field of cancer control, health education in the community, relations between professional disciplines, and the relationship between patients and physicians. The discussion of the patient-physician relationship points to demonstrable differences in health beliefs and power, as well as compounding factors, both social and cultural, that can impede the appropriate delivery and acceptance of health information.

Cancer in the Community is an ethnographic case study set in Tannerstown, a working-class neighborhood north of Philadelphia. The focus is on the health beliefs of the residents (primarily concerning the causes of cancer) and the attitudes and assumptions of outsiders about the Tannerstowners. Using questionnaires, interviews, selections from the print media, community health-education programs, observations, and personal experience, the author builds a case to substantiate her thesis that the power differential -- class differences between the residents of Tannerstown and the medical community and within the scientific professions themselves -- creates an unfavorable environment for health promotion.

A particularly engaging chapter, “The Study Community,” draws the reader into the lives and experiences of the Tannerstown residents, who are living in a cancer “hot spot.” Their voices are captured in quotations taken from astutely analyzed research materials. The brief historical and demographic description of Tannerstown provides a context for the issues raised by the research.

Project CAN DO, the health-promotion effort described in this case study, illuminates the complexities and incompatibilities of the author's dual professional role as anthropologist and health educator, as well the complexities inherent in the nature of the project.

The author's contention that the disparity in beliefs is based on class and medical authority is illustrated with a case example in the chapter, “A Cancer Death.” The conflict is illustrated by two interviews: one with the wife of a man who died from cancer and the other with one of his attending physicians. Face-to-face interviews can provide the rich in-depth material that one seeks in qualitative research. Unfortunately, the material in these interviews is too thin, primarily because of the four-year lapse between the patient's death and the interviews. The most serious consequence is that the events have lost much of their emotional impact and thus appear to be devoid of life. The physician had to respond to the interview questions on an academic and theoretical basis because he did not recall the patient or the details of his illness. As the sole representative of medical authority in this study, the physician expresses a viewpoint that is not authentic and does not provide the necessary balance to the argument regarding class and medical authority that is needed to substantiate the thesis of the book.

Some excellent and provocative material in this work occasionally gets lost in the author's personal conflict about her roles as a researcher, anthropologist, health educator, and person looking for approval from the community and from her colleagues in two disciplines. The use of the “felt experience” could have been more productive if the ethnographer had been closer to her material and more distant from the analysis, as Renee Claire Fox managed to be in Experiment Perilous: Physicians and Patients Facing the Unknown (Glencoe, Ill.: Free Press, 1959).

This book addresses the serious issue of power relationships within scientific medicine and between doctor and patient, medicine and the community. By implication, the more critical issue is the need to provide medical care and health education in a manner that is compassionate, accommodates cultural differences, and does not interfere with people's chosen lifestyles.

The author might have looked at the biopsychosocial model of medicine (G.L. Engel. “The Need for a New Medical Model: A Challenge for Biomedicine.” Science 1977; 196:129-36) to find a workable framework for understanding and solving the problems raised in her study. The importance of negotiating the meanings and goals of health is implicit in this model, as is the notion that making assumptions about the genesis of problems is a problem in itself.

This book will be valuable to anyone interested in the issues involved in bringing health to the community and providing appropriate health care institutions. In addition, it will be welcome reading in research courses, giving students insight into the myriad concerns of an ethnographer in the field.

Tovia G. Freedman, D.S.W.
University of Pennsylvania, Philadelphia, PA 19103