Gita Sen, Asha George and Piroska Osltin (Eds.) Engendering International Health: The Challenge of Equity.

Cambridge, MA: MIT Press, 2002 $24.95 papercover.

For at least the last twenty years, health theorists have employed social epidemiology to better understand the distribution of health and illness among various populations. Most of the research in this area has concentrated on three main factors, races, sex and income, a set of variables that have sometimes been called the 'Holy Trinity' of social epidemiology. Data about these variables are readily available, and each has been shown to have a significant impact on health status. The editors of Engendering International Health: The Challenge of Equity, and the numerous authors who contributed to the book argue that to more fully comprehend the distribution of health and illness, one needs to include not only sex, but also gender in one's analysis. They posit that these two variables, biologically determined sex, and socially defined gender, have significant impact on health status, especially through social roles that delimit how women and men behave, work, and reproduce.

The book begins with an excellent introduction to the themes of the text. The editors of the text lay the groundwork in this chapter for the rest of the book. Sex and gender are clearly differentiated, and the various pitfalls and difficulties of separating their unique impacts on health are discussed fully. They provide a clear explanation of why and how gender has been largely overlooked in social epidemiological studies of health status. They also examine the importance of the intersections among race, age, income status (in particular poverty) and gender. This single chapter provides an essential framework for including gender in health study. The remainder of the book is divided into two sections: key health area, and health research and policy. The health areas included are communicable diseases; work and its effects on health; reproductive health; violence against women; mental health; hip fracture; and, health and the environment. The research and policy section includes two chapters on gender, race and class--one examining these issues in the United States and the other in India. The remaining chapters in this section are on policy environments, health status measures and health sector reform.

Each of the key health area chapters follows the same format. They begin with a description of the issue, its distribution in various populations, a gender analysis, and end with discussions of research and policy needs to further address the areas. The policy chapters do not follow a specific format, although each describes its subject and then includes a careful gender analysis related to its specific focus.

This is a strong book with few, but at least one notable weaknesses. The content is meaningful and the focus on international health provides opportunities to compare developed and developing nations with regard to both their population health status and the different gender roles and its impact. Although the primary focus is on women's health, the impact of gender roles on men's health is not overlooked. What is omitted is an analysis of the impact of sexual orientation/identity on health. This is surprising given that the effects on health of a person's sexual orientation/identity are equally as socially grounded as are the effects of gender, and in some person's definitions sexual orientation is part of gender identity.

The policy section of the text is not as strong as are the health area chapters. There is some considerable redundancy in the content, especially with regard to discussion of measures. The chapter on measures is clear and complete, and the inclusion of further analysis of those measures in other chapters is not needed. The final chapter focuses on health sector policy reform, but is located fully in developing countries. Important as this is, those of us searching for health sector reform in the United States may find ourselves frustrated by the lack of discussion of this most pressing issue.

Except in a course on women's health, this book may be difficult to use as a text. In addition to the obvious limitation of the primary focus on gender, its organization of covering both health areas in a theoretical perspective, followed by policy issues may make it difficult to locate in a single class. I may use some of this text in the course that I teach on the behavioral, psychosocial and environmental aspects on health and illness. I would, however, probably not use the entire text. The introductory chapter provides the necessary framework for expanding the discussion of social epidemiology to include gender (and in my teaching, to include sexual orientation, as well). I would suggest that students read health area chapters that inform research for their for the various class assignments, however, I would be somewhat reluctant to use the policy segments of the text--mostly because they do not fit with the course. In contrast, I might want to assign at least a few of the chapters for reading in my health policy class, especially the ones related to measurement and policy environments. Regardless of whether it is used as a primary text, a secondary one, or to provide background for preparing classes, as a university professor, I find this a valuable book and suggest that others teaching health courses will find it so.

Deborah Schild Wilkinson

University of Michigan