Feminine complaints

The Harvard Guide to Women's Health
May 3, 1996

If only all women were in a position to welcome this authoritative book on women's health by three American female academics - a rare publishing event in a competitive market. Sadly for the authors and publishers, The Harvard Guide to Women's Health will appeal to a narrower segment of the health- reading public than they might have wished, at least in the United Kingdom. It is a learned book. It is for blue stockings, blue stockings and health professionals who will undoubtedly be better informed for referring to it. But user friendly it is not.

On the positive side, this book has a head start on almost all the others around for the simple reason that everything in it is based on scientific fact and it is therefore free of hyperbole, distortion and prejudice. It is also steadfastly accurate and up to date. On the other hand, some readers may be disappointed to see that unorthodox topics like alternative therapies are dealt with in only four pages (out of 718), possibly a reflection of the book's academic provenance, and to make way for Alzheimer's disease - an uncomfortable but unavoidable shift of weight imposed by the alphabetical order of contents. And it comes as quite a shock to find that episiotomy, the cut that is made to let the baby's head out in childbirth and the most overperformed unnecessary surgical intervention in western medicine, while mentioned here and there, is not given a section to itself. No, we go from Epilepsy to Estrogen.

So it is not quite definitive, this dry, doctorish book. Nonetheless if you want the latest American encyclopedic volume on your reference shelf it could be the book for you. But, oh, it is difficult. On thumbing through it I am reminded of nothing more than my undergraduate clinical textbooks, and some postgraduate ones, too: pages of tight, unrelieved text; uncompromising no-nonsense line-drawings by way of illustrations (hardly a photograph in the book, not a trace of colour); precious few explanatory subheads signposting the real issues. All this summons up memories of pre-exam swotting late into the night with great tomes too heavy to read in bed. By comparison, Our Bodies, Ourselves opened at random yields, "Infertility treatments: the dilemmas they raise". That's more like it.

The book comes with an excellent pedigree, hailing as it does from Harvard Medical School but herein, paradoxically, lies one of it is weaknesses. As with much medical (and scientific and technological for that matter) writing the authors put their information before their reader - put their peers before their reader. The result is a textbook, not a self-help manual, which is what I think the authors would have preferred to have written. They make their goal clear in the preface: "We wrote this book I to give women the knowledge they need to communicate effectively with their doctor, and to become partners in taking good care of their health."

Good aims and shared by all writers who address women's health, but knowledge on its own is not enough. To convert knowledge into action most of us need some spur in the form of emphasis, priority, ranking, not to mention checklists, step-by-step action plans, where to go for help and so on. Reading this book I recall watching Jonathan Miller on BBC2 talking to camera on how babies learn to speak - and thinking that the subject was too important to be this highbrow. BBC2 mode just will not do. Crucial topics deserve to be presented BBC1-style. And so does this book. The average woman will need an interpreter, will long for pictures, graphs, pie-charts, boxed-off topics in the manner of Time and Newsweek, yes, even X-rays, cardiographic tracings, photographs of normal and osteoporotic bone structure - whatever - to make the text accessible, digestible, appealing and alive. It is not as though we lack a precedent. The Boston Women's Health Book Collective's, My Body My Health, It's Your Body, health encyclopedias, originating in the United States, did this kind of thing earlier, better - the first of the aforementioned in 1977.

All this makes one feel that there is some confusion about who the book is intended for. She is not someone without eight or nine O levels. She is not someone who finds it easy to tease out from parentheses, waivers, qualifiers and technical terms the gold nugget she might act on. She is not someone who likes to have the pros and cons of a question tabulated so that she can scan the information and arrive at a fairly rapid conclusion about where she stands. She is not someone who can take chunks of negative information in her stride in coming to a working decision. Between pages 337 and 338 we are given 88 lines on the risks and complications of intra-uterine devices. The subject could be covered succinctly and accurately in much less space and without being so downbeat.

In one respect this is another hazard of academics writing for lay people. The academic model is never to come down on one side of an argument or the other but simply to present information tonelessly and allow the reader to judge for herself. Academic writing is plagued with what is called fair balance - it may be fair but it is not necessarily intelligent or helpful and it hides behind ambiguities that constantly seek to avoid warrantee so the message gets muddied. But this is the American way with medical information for the public arena. Take a look at the US patient-pack inserts that go with pharmaceutical products, ostensibly to inform but in practice doing the opposite. The American pack insert with its endless disclosures clearly is not written to inform, clarify or reassure the patient. It is written by lawyers and its legalese is there to protect the company from a law suit. When writing with the stated goal of helping women deal with health questions there is no need to sound like a government regulatory authority carefully guarding its back.

The American experience dies hard. I look for the entry on hormone replacement therapy (HRT) and find "see estrogen replacement therapy (ERT)" suggesting they could be synonymous. They are not, at least not in Europe. More than 25 years ago I became involved with research into hormone replacement therapy, as opposed to estrogen replacement therapy, which incorporated a progestin (a relative of natural progesterone) into the estrogen regime for reasons of safety. HRT, in any other form, has never been used in Europe to any extent, so it comes as something of a surprise, to read "I the addition of progestins, which only recently (my italics) became a routine part of most ERT". Only in America.

The blurb from Harvard University Press hails the book as a, "Definitive reference [that] offers comprehensive information on all health issues concerning women" - warranty if ever I saw it - and then proceeds in an oddly dated tone. What are we to make of "it addresses concerns that are not articulated, often out of a sense of privacy, embarrassment, or perhaps denial, but have a profound impact on a woman's health - concerns about domestic violence, rape, eating disorders, substance abuse, sexual preference, breast reconstruction and abortion - all presented with a balanced perspective"? Where have the authors been these past 20 years? Come back Erin Pizzey and Sheila Kitzinger, all is forgiven. Don't they ever switch on Oprah? A recent Sunday newspaper carried a story on eating disorders where a helpline took 38,000 calls on two lines last year and that figure only dented the 238,000 who did not get through but who presumably were articulate, unembarrassed and not in denial.

And just a brief word on tonelessness. The book offers no female take on health issues. In the vernacular, it is a book without attitude. It delivers no badly needed corrective to decades of male medical bias. We cannot afford to be toneless about women's health issues, not when the first research ever into heart disease in women began only a few years ago. Before that cardiac research had been done only in men. It is the duty of writers in the field of women's health to keep pushing the pendulum back to centre from its eccentric male position. Three outstanding female medics may have missed an opportunity here.

Any three authors who put together more than 700 pages on women's health deserve congratulation, however, and there is much detail to applaud in this book, but I return to my earlier question, who is its reader? Is it for people like me, medically qualified, who would turn to it as a reference book (and I would) but who would always have to translate it for general consumption and correct its American orientation. Is it for health professionals and educators? Yes, and it would do its job well. It will not let you down if you have the time to annotate, enumerate and precis. Is it for the uninformed, unassertive woman who does not have the wherewithal to seek out information and support, who is timid with anyone in medical authority, who needs practical help in forging any relationship with her doctor and who, heaven knows, needs help more than any other woman? Well, no, sorry, it is not. If it is meant for the needy woman could doctors Carlson, Eisenstat and Ziporyn please do it again, and next time humanise it a bit.

Miriam Stoppard's latest book is The Menopause, 1994.

The Harvard Guide to Women's Health

Author - Karen J. Carlson, Stephanie Eisenstat and Terra Ziporyn
ISBN - 0 674 36768 5 and 36769 3
Publisher - Harvard University Press
Price - £25.50 and £15.95
Pages - 718

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