Review Author(s): Elizabeth Fee Review by: Elizabeth Fee Source: Journal of Public Health Policy, Vol. 8, No. 4 (Winter, 1987), pp. 584-587 Published by: Palgrave Macmillan Journals Stable URL: http://www.jstor.org/stable/3342285 Accessed: 27-04-2016 19:52 UTC Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://about.jstor.org/terms

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584 JOURNAL OF PUBLIC HEALTH POLICY WINTER I987

ment all over Europe. This strong reaction, it is said, probably contributed

to Semmelweis' death in August I 865. He was literally beaten to death while hospitalized in a mental home (by then another common iatrogenic procedure!) The exchange of letters between Semmelweis and his foes, as well as the excellent introduction by K. Codell Carter, provide all the details needed to understand the drama that surrounded Semmelweis' life, work and death. The solid scientific criteria used by Semmelweis to solve the problem of childbed fever, and the importance of his findings, make this book one

of the landmarks in the field of epidemiology and give it an amazing contemporary value. CLOVIS H. TIGRE

Irene Butter, Eugenia Carpenter, Bonnie Kay, and Ruth Simmons. Sex and Status: Hierarchies in the Health Workforce. Washington, D.C.:

American Public Health Association, I985. 77 pp. $5.oo paper. This tightly argued monograph places the issue of sex discrimination in the health labor force on the policy agenda for the United States in these last decades of the twentieth century. The authors document the extreme

patterns of sex segregation in the health work force, and provide an intelligent discussion of three major areas of concern: the integration of women into predominantly male professions, the impact of licensure and credentialing on work structures, and the use of comparable worth in evaluating health sector jobs. This brief but focused book introduces the new Public Health Policy Series, published by the American Public Health Association, which is intended to draw attention to current and emerging

issues in health policy.

The gender-based division of labor in the health work force has remained fairly consistent throughout the twentieth century, despite enor-

mous growth in the size and complexity of the job structure. Women comprise over 75% of all health workers, but are rarely represented in the corridors of power, in major decision-making roles, or in positions of executive authority. The authors show how traditional "masculine" and "feminine" roles have been institutionalized and rigidified in the hierarchical structure of the health labor force, along with the much higher social valuation placed on "masculine" roles and activities. All

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jobs concerned with caring, consoling, counseling, nursing and nurturing, for example, tend to be poorly-paid and female-dominated. Jobs dealing with the use of procedures and devices in diagnosis and treatment, technical functions and services, and jobs with high levels of autonomy, on the other hand, are largely restricted to men. The authors note the

implicit values inherent in the structuring of the labor force: a low social

and economic value is placed on the promotion and maintenance of health, on personal relationships and "caring" skills and functions; a high social and economic value is placed on technical skills and technological interventions, and on the range of "curing" skills and functions. These valuations reflect and reproduce the traditional division of labor by gender and the social devaluation of "women's work." Equal Opportunity and Affirmative Action legislation has opened up a small group of "elite" health occupations to women; in the health sector, increasing numbers of women are becoming physicians. Here, the authors review the data on women in medicine, showing that there has been some change in the pattern of women entering the lower status specialties: more women are now going into internal medicine and obstetrics. Women still tend to cluster in institutional settings and occupy salaried positions; women physicians make, on average, 70% of the incomes of their male colleagues. Few women are in the highest status positions for example, no medical school has a female dean. The strategies suggested for change at the top level of the health hierarchy seem weak; these range from job sharing to management courses

for women. At no point do the authors suggest or seem to imagine that women in medicine could be at an advantage, or that women might be able to change the structures of medical care in a way that could benefit both practitioners and patients. The subsequent chapters are both more imaginative and more optimistic. A very interesting discussion of credentialing, for example, looks at the barriers to women's occupational mobility within the health labor force. A brief history of licensing shows how state medical practice acts have allowed physicians the power to define and restrict other health

sector professions, including most of the "female" professions. The authors show that, in general, job stratification and sex stratification are reinforced and perpetuated by licensure; they also recognize, however, that once the system has been established, it is often to the immediate benefit of occupational groups to struggle for new licensing statutes as a path to increased professional status and a means to third party pay-

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586 JOURNAL OF PUBLIC HEALTH POLICY WINTER I987

ment for their services. The final result of the system of licensure and credentialing of each separate occupation, however, is to fragment the

work force, to erect barriers to movement between occupations, and to block career mobility. The health labor force is thus divided into a multitude of exclusive boxes, with little possibility of horizontal or vertical movement between jobs. Once in a defined occupation, the only way forward may be to start all over, by returning to entry level in another

health occupation. The authors' analysis clearly questions the strategy of upward mobility

for women health workers through credentialing mechanisms: while appearing to offer professional status and security, this strategy actually

locks allied health workers-predominantly women-into dead-end jobs. A major effort at restructuring health occupations and educational programs might offer possibilities for mobility, "career ladders," more flexible educational preparation, and a more open process of credentialing. This monograph poses the question; nurses, allied health workers, and others concerned with the structure of the health labor force would do well to take this analysis as a starting point for considering long-term

strategies and policy solutions.

The final chapter of this monograph offers the most radical and optimistic program for redressing gender inequities through the means of

comparable worth policies. Despite the publicity surrounding women's increased entry into professional positions, women's pay still stands at 63% of male pay -actually below the ratio for women's earnings in I955. In dealing with a labor force where jobs are strongly segregated by sex, one way to move beyond this economic disparity is through the principle of equal pay for jobs of comparable worth. In virtually every case where efforts have been made to evaluate the actual content and skill level of specific jobs, women's occupations have been found to be dramatically underpaid. One federal district judge has declared that comparable worth is "pregnant with the possibility of disrupting the entire economic system of the United States" (p. 67), a statement that implicitly

recognizes the depth of occupational discrimination against women. Any effort to formally evaluate jobs in the health sector would raise familiar questions: are health jobs evaluated according to financial measures, such as increased revenues for a clinic or hospital, or by measures of improved health status and health outcomes? How is responsibility for human life measured in relation to "managerial know-how," specific technical skills, or the stresses of mental health counseling in a commu-

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nity? A valuation of jobs would have to wrestle with the often conflicting

objectives of working to improve the public's health, maintaining and improving the financial viability of an institution, or increasing basic medical knowledge through laboratory research. Perhaps it is high time

such issues were explicitly raised; comparable worth studies, in examining the real structure of health sector jobs, may well pose profound questions about the values of our health care system. My major disappointment with this otherwise excellent monograph was its failure to address the interrelation of race and gender inequities. It seems reasonable to assume that much of the analysis applies to both Black and white women, and that issues such as comparable worth studies could simultaneously address gender and racial discrimination. Unfortunately, much of the literature on stratification of the health labor

force addresses gender segregation without regard to race, or racial discrimination without regard to gender, resulting in the peculiar invisibility

of the situation of Black and other minority women. This information vacuum tends to be filled by the extraordinary, yet popular, notion that Black women enjoy special privileges in the job market. More studies of

the relationship of gender and racial occupational segregation and discrimination could help lay a firmer basis for efforts to remedy inequities in the structure of the health labor force. Despite this caveat, Sex and Status provides an extremely helpful discussion of gender discrimination; one may hope that the final chapter on comparative worth could indeed

be the beginning of a serious reexamination of ancient and outdated patterns of sex-segregated labor at all levels of the health hierarchy. ELIZABETH FEE

Rashi Fein. Medical Care, Medical Costs: The Search for a Health Insurance Policy. Cambridge, Mass: Harvard University Press, I986. iX + 240 pp. $20.00.

This is an elegantly written, thoughtful book that reviews the history of the conflict over national health insurance (NHI) in the United States

during this century and makes recommendations for the future. In the process, Fein discusses the development of private health insurance, the political history of Medicare and Medicaid, the problems in their implementation, and the efforts to reform the health care system in the seventies and eighties. Present-day practices and peculiarities, subtle and

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