108 Book Reviews 
These questions refer to two measures of use, 'ever-use' and 'current-use'. 
Current use or contraceptive pervalence must only consider responses to the 
first question. Responses from the second question can be used if data on 
contraception are diffentiated by method of use in which case women who, for 
instance, had an injection a month prior to the date of the survey, are 
legitimately current contraceptors assuming a three-month protection. However, 
if differentiation by method is not made, as is the case of the ZRHS, a 
combination of responses to both questions inflates the contraceptive prevalence 
figures. If the contraceptive prevalence is indeed a true representation of 
reality, the implication is that Zimbabwe needs a much higher level of 
contraceptive prevalence to achieve an equivalent proportionate reduction in 
fertility. 
In summary, then, it can be said that the ZRHS report provides invaluable 
information for planning and implementing programmes to effect fertility. 
However, it is disturbing to note that estimates of very important indices 
deviate from those of the national census. While the reconciliation of these 
differences is definitely beyond the scope of such a report, one cannot 
underplay the exigency of such an exercise if the estimates are to be 
meaningfully utilised for any future planning with an acceptable degree of 
confidence. Perhaps cautionary footnotes would have been helpful. There is 
also an inconsistency between the reported high (positive) determinants of 
contraception and the reported level of contraception. Perhaps the determinants 
in this report are of little significance to the adoption of fertility control in 
Zimbabwe, but this is doubtful. However, these few shortfalls must not 
overshadow the acceptability of the ZRHS report as an important document on 
Zimbabwean fertility. In this report lies a strong foundation for future research 
and planning. 
Reviewed by Marvelous Mhloyi, University of Zimbabwe, Harare 
Reference 
BONGAARTS J 1984 "A Simple Method for Estimating the Contraceptive 
Prevalence Required to Reach a Fertility 
Target" in Studies in Family Planning 
15(4), 184-190. 
David Sanders with Richard Carver, The Struggle for Health: Medicine and 
the Politics of Underdevelopment. Macmillan Publishers, London, 1986, 
£2,95. 
This book has been written for the general public but is particulary useful to 
health professionals, the business community and politicians. It is written in 
clear and easy to understand language, makes use of extensive examples from 
developing and developed countries and is well illustrated. It is an excellent
Book Reviews 109 
exposition of the real causes of ill health in both developed and underdeveloped 
countries. 
The first two chapters compare the disease pattern of late 19th century 
Europe and present day underdeveloped countries. The disease pattern is 
similar, consisting mainly of infectious diseases. It is noted that the decline in 
deaths in Europe was largely due to improvements in living and working 
conditions. Specific medical intervention had very little role to play. This is 
echoed by the fact that even in Britain today, where there is a National Health 
Service available to everyone irrespective of social class, there are clear 
differences in disease patterns amongst the different social classes. This 
reinforces the fact that living and working conditions are more important than 
medical services in improving the health of any population. 
In Chapter 3 Sanders looks critically at the population dilema. He argues 
that the West would like us to believe that economic development in 
underdeveloped countries is hampered by unchecked population growth. We 
are told that the population explosion is the cause of famine, poverty and 
disease. It is this notion that led to the rapid proliferation of family planning 
programmes in the early sixties and even now such programmes are seen as a 
solution to poverty and underdevelopment. Massive resources have been and 
are still being poured into population control programmes for this purpose 
especially by the USA: Asians, Africans and Latin Americans are being told 
that they are poor because they have too many children. 
Sanders and Carver argue that famine is due to inappropriate production of 
food and the inequitable distribution of the same. Poverty is due in part to 
grossly unfair land distribution systems and also to the fact that capital is in the 
hands of a few foreign and local capitalists. 
The truth is that population growth is a natural phenomenon which takes its 
own course - the so called demographic transition. High mortality and fertility 
is usually followed, after a lag period, by a decline in fertility. Countries are in 
different periods of demographic transition and will stabilise with time, with or 
without active intervention. In underdeveloped countries, fertility is high 
because of high mortality. In India, for instance, a couple has to have about 
seven children in order to be 95% confident that one survives! It is therefore 
not surprising that family planning programmes have had no effect on 
population growth. Good examples of this notable failure are India and 
Pakistan where family planning programmes have been in existence for a very 
long time and yet they have not had a noticable effect on population growth. 
After all, European fertility declined without much reliance on modern 
contraception. 
What Jias been the medical contribution in improving the health status of 
communities? Most resources have been spent in building, equipping and
110 Book Reviews 
manning large hospitals in urban areas. In underdeveloped countries these 
'disease palaces' serve only 20% of the population since 80% of the 
population live in rural areas. Therefore the majority of the population has no 
access to any meaningful medical care system. It is therefore not surprising 
that these huge investments in medical care have failed to have any impact on 
morbidity and mortality. It has also been noted that even if there is equal 
access to medical care, the impact on the health status will still be negligible. 
Chapter 5 is a review of the role played by the health professionals, business 
community and the state. It is concluded that the medical profession is there to 
serve the interests of those in power and in fact it helps to strengthen the status 
quo. The business community, too, resists pressure for improving living and 
working conditions. Lastly the drug industry is an economic burden on the 
already meagre resources available for health services, especially since most 
of the drugs may not have any therapeutic value. The drug industry therefore 
shifts resources away from the fundamental causes of ill health. 
The last chapter addresses itself, more positively, to the solution to the 
problem of underdevelopment and ill health. It is now well recognised that 
health problems are rooted in social conditions. In developing countries this is 
worsened by the international system that seeks to perpetuate underdevelopment. 
An attack on these social conditions will no doubt go a long way to 
improve the well-being of communities. Two striking examples, China and 
Cuba, are discussed to show that revolutionary changes in the socio-economic 
conditions can bring about a decline in diseases and deaths due to preventable 
conditions. It must be stressed that a high degree of political commitment was a 
prerequisite for the success that both these countries claimed. Changes in the 
health sector follow rather than precede fundamental social change. Instead of 
depending on doctors a more appropriate health worker who is community 
based may be more acceptable to the people. A good example of this is the 
Chinese 'barefoot doctor'. China owes its success in the health 
sector to this cadre of health worker. Most developing countries now rely on 
this community health worker. He or she is chosen by the community and lives 
in the community and is therefore accessible to the community. This is the 
cornerstone of Primary Health Care which has revolutionised the medical 
myth. Through the Primary Health Care approach, health workers can help 
fight underdevelopment by stimulating communities actively to participate in 
promoting good health - thus struggling for their own health. 
I would recommend this book to all health workers and policy makers, 
especially to those people who wish to know the real reasons for ill health. The 
central argument is that ill health cannot be separated from underdevelopment 
Reviewed by Ephraim Minya, Ministry of Health, Bindura.