Book Review

An Unfinished Revolution: Women and health care in America

N Engl J Med 1995; 332:1387-1388May 18, 1995

Article

An Unfinished Revolution: Women and health care in America
Edited by Emily Friedman. 285 pp. New York, United Hospital Fund of New York, 1994. $20. ISBN: 1-881277-17-8

Women dominate the health care industry. As providers they make up more than 80 percent of the health care work force, and as consumers they average one third more visits to physicians than men. Moreover, almost all home health care, including the care of elderly parents, disabled children, and chronically ill relatives, is provided by daughters, daughters-in-law, wives, sisters, and sisters-in-law. None of this information is new.

What is new is the increased participation of women in the parts of the health care industry that have traditionally been the domain of men. In 1970, 9 percent of medical students were female, as compared with more than 40 percent today. Moreover, women are now hospital trustees, health policy makers, and officials at the highest levels of government. Furthermore, there is greater awareness of, and involvement by, women as consumers of health care, a change largely attributable to the feminist movement and to the general increase in patient autonomy in health care.

This combination of the continuing participation of women in health care and changing roles and expectations for women led Emily Friedman, a medical writer and health policy analyst, to organize a conference in 1990 entitled “Taking Care: the Impact of Women on Health Care,” sponsored by the United Hospital Fund of New York. An Unfinished Revolution: Women and Health Care in America is the result of that conference. The contributors to this book are recognized experts in their fields.

The book has four sections, on women as users of health services, women and informal care giving, women as health care providers, and women as health care leaders. A theme throughout is the effect of broad social change on health care, as more and more women work outside the home, reach higher levels of education, and insist on equality of opportunity. The book also points to numerous responsibilities that have been traditionally assumed by women and are not yet shared by men. A recurrent theme is the presence in health care of the social problems that beset women everywhere: unequal pay for equal work, sexual harassment, the traditional imbalance in male–female relationships, and the competing demands of work and family.

Several chapters make noteworthy contributions. Joan Lynaugh provides a detailed history of nursing, describing the essential role of this profession and the effect on it of changes in medical knowledge. Phyllis Kopriva compares medical specialties in terms of the participation of the sexes, describes continuing barriers to the advancement of female physicians, and provides policy recommendations for further change. Charlotte Muller describes the many allied health care professionals, such as physical therapists, dietitians, and medical assistants, who are predominantly female and without whom the health care industry could not function. Carolyn B. Lewis shows the changes in outreach and practice that can be achieved when women, including women from the community, are included on hospital boards.

As with other books with contributing authors, the chapters are of variable quality. Two chapters address the issue of race and sex, although several others neglect this important issue. Even less attention is directed to the role of class in access to health care and advancement in the health care professions. The book does not directly address the health status of women generally and the effect on it of their underrepresentation in clinical and epidemiologic research.

“An unfinished revolution” is an apt title for writings on women in health care. “Revolution” implies dramatic change, and this book documents how certain women have taken control of their own health care and become leaders in health care disciplines and institutions. At the same time, the revolution is far from finished. The women who have benefited from the changes are usually better educated, the women who have better access to care are usually wealthier, and inequities remain at every echelon of the medical profession. It remains to be seen whether managed-care arrangements and reduced funding for social programs and medical research will propel this revolution forward or backward. This book will raise the consciousness of its readers, be they students, health professionals, or women and men willing to explore these sometimes uncomfortable issues.

Nancy Kass, Sc.D.
Johns Hopkins School of Public Health, Baltimore, MD 21205

Amalie Kass, M.Ed.
Harvard Medical School, Boston, MA 02115