Health Education Research, Vol. 16, No. 1, 101-102,
February 2001
© 2001 Oxford University Press
BOOK REVIEW |
Health Work with the Poor—A Practical Guide
Christie W. Kiefer Rutgers University Press, New Brunswick, NJ, 2000, 240 pp. ISBN 0-8135-2777-5 (pb)
Primary Nurse, South Leeds Community Unit Day Hospital, Community & Mental Health Services, Leeds
As a Professor of Anthropology, Kiefer would appear to be well placed to consider the importance of health work with the poor. His background knowledge, linked with an evident concern, makes this an ultimately rewarding read, but the journey is not for the faint-hearted.
Even today the idea remains that England and America are divided by a common language, which makes this an important work, straddling as it does the combined specialisms of health care and social work. Where phraseology and spellings differ (I admit to thinking the title was intended to be `Health Work with the Poorly') the overwhelming unifying similarities are in the political arena.
Less than a page into the Preface the point is stressed that `some readers may see in this book an indictment not only of the American health care system, but of many other institutions that affect the poor'. Indeed, it is difficult to reach a radically alternative conclusion.
Having completed his doctorate at Berkeley in the 1960s, Kiefer's 30-plus years of experience have enabled him to synthesize the information available into a genuinely practical guide, rather than an academic treatise—one of his stated objectives. However, this is not merely an experiential merry-go-round where the growing realization of major problems within capitalist society have to be confronted, where poverty `evokes sympathy in the abstract, but aversion in the concrete' (p. 15), but the acceptance that the often gripping drama of health care affects every individual.
Much is made of an historical overview to explain the causes and effects of poverty, where often `our pleasures are now allocated on the basis of class and wealth' (p. 47), but it hardly takes Oscar Wilde to draw solace from the media circus surrounding minor celebrities and their football kicking paramours. Class and wealth—for some—equates with an OK! photospread, apparently. A need for control seems integral, as is the recognition that many faiths carry the message that suffering is not pointless, but part of a larger plan.
One of the most pointedly satirical political images of the 1960s was of Harold Wilson being Lyndon B. Johnson's `poodle' and of the American presidents surname lending itself to the rhyme `how many kids did you kill today?', but perhaps the time is now right to re-evaluate LBJ. With direct reference to Erikson's `pseudospecies', Kiefer remarks on the `us' and `them' mentality that
Politicians try to make use of our tendency to extend our fellow feeling to abstract entities like nations, but it can backfire. Although his administration marked a high point in social reform legislation, Lyndon Johnson was unpopular in his last years as president. With his heavy Texas accent, he used to begin every speech with the words, `My fellow Americans...'. For millions who found his policies in Vietnam horrible and his accent strange, his attempts to establish kinship with his opening cliché helped to destroy his credibility. (p. 13)
Johnson's administration marking a high point in social reform legislation is particularly important within the context of the argument about poverty in America and even perhaps, globally. The growing Civil Rights movement of that period intriguingly echoed the 1930s Great Depression—`the two most vigorous efforts to relieve poverty in the US' (p. 89). That both epoch-making periods were accompanied by widespread, often violent, public protest is also noted.
By way of discussing the politics of explanation for poverty, Kiefer cites a quote from Newt Gingrich, made as House Speaker, in 1995—`I am prepared to say to the poor, "You have to learn new habits. The habits of being poor don't work" (p. 27). Across the political divide, a brief mention is made of Paul Wellstone, as liberal as Gingrich is conservative and who has a history of `association with people on the bottom, with welfare mothers, farmers, labourers, workers' (McGrath and Smith, 1995
).
Divided into three distinct sections, Kiefer's book considers the relationship between health workers and low-income clients, moves towards social analysis, and concludes with a summary of the move towards community organizations. The crux of the middle chapters focuses on what could be considered to be a post-permissive backlash—unwed pregnancy, for instance, is discussed in the clumsily labelled `Teenage Pregnancy Bag' (pp. 101–105). Other topics studied include the enforced sterilization issue and the debate about whether criminals use drugs or drug users become criminals.
Catalogues of horror stories that happen to people under managed care are alluded to and radical suggestions to combat poverty are considered—the obstacles `are enormous, but not insurmountable' (p. 121).
Of particular importance is Chapter 6, which gives a comprehensive overview of the health problems that face the poor and the honest appraisal is in keeping with the general tone of this paperback. Devastating statistics pepper the discussions—40 million Americans, most of whom can be classified as the working poor, have no health insurance cover.
In some ways, Kiefer presents a potted history of the anomalies of the American legislature, with the regular moves between Republican and Democrat majorities itemized. Interestingly, the growth of Community Health Centers stemmed from the 1960s, when War on Poverty bills were introduced, but it was not until 1988 that `Over 60' units identified the need for facilities and staff to manage Alzheimer's patients.
It is perhaps pertinent to end on a note of optimism—in 1995 over 31 million people visited the 2200 Community Health Centers in America, but Kiefer remains confident that the staff have an overwhelming commitment to adapt to the growing needs of the wider political and economic environment. So there you have it—the struggle continues, and is passed on to the next generation of legislators, health workers and social reformers. God Bless America?
Reference
McGrath, D. J and Smith, D. (1995) Professor Wellstone goes to Washington. University of Minnesota Press, Minnesota, MN, p. 12.
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