"Bare-handed" medicine and its elusive patients: The unstable construction of pregnant women and fetuses in dominican obstetrics discourse

Feminist Studies

Volumn 23, Issue 2, 1997, Pages 263-288

  Ortiz, Ana Teresa ^a  

^a NONE

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[No Author keywords available]

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EID: 0039468147     PISSN: 00463663     EISSN: None     Source Type: Journal    
DOI: 10.2307/3178397     Document Type: Article

References (49)

1. These limited options were at the root of the differences between some "mainstream" abortion rights and feminist groups, and feminist labor activists and antipoverty activists, in their reactions to the pivotal case of UAW v. Johnson Controls (1991). In reviewing this case, the U.S. Supreme Court found that "fetal protection policies," workplace regulations that barred fertile women but not fertile men from"risky" (and not coincidentally) lucrative work assignments, were discriminatory. Some labor and poverty-rights activists felt that by attacking the notion of fetal personhood, organizations such as NOW and NARAL were making it more difficult for working women to fight to receive compensation for desired pregnancies lost to workplace health hazards (personal communication to author by staff at the Massachusetts Coalition for Occupational Safety and Health and Boston Women of Color for Reproductive Freedom). For a concise synopsis and analysis of the case, see Cynthia Daniels, At Women's Expense: State Power and the Politics of Fetal Rights (Cambridge: Harvard University Press, 1993). Anthropological research on varying and culturally specific understandings of fetuses, newborns, and persons has enriched and enlivened discussion of fetal personhood by affording some autonomy from the U.S. context and its high stakes, even as cross-cultural studies are simultaneously explored as resources by U.S. feminists, who can invoke relativism and the wealth of human diversity to strike out at antichoice arguments built on culturally specific ideas about "nature," "natural order," and "scientific fact." References to practices of infanticide of twins or breech-birthed neonates among romanticized Others-practices defined internally as the elimination of nonlife or "abominations"-are entering the rhetorical stockpile of prochoice activists, in a fashion that should not go unexamined by feminists wary of contemporary colonialist turns. For example, discussion in one prominent women's health text of historical and anthropological perspectives reaches its climax by sensationally stating that "anthropologists reported one society in which the aborted fetus is fed to its would-have-been siblings." See Nada Scotland, "Contraception and Abortion: Challenges Now and for the Next Century," in Reframing Women's Health: Multidisciplinary Research and Practice, ed. Alice Dan (Thousand Oaks, Calif., and London: Sage, 1994), 143. In parallel fashion, such examples are appropriated by right-wing opponents of abortion rights to invoke a "slippery slope" in which concession of fetal life throws into question the visibility and value of the lives of children, elders, people with disabilities, and so forth, and to frame diversity of opinion and fetal personhood as part of a greater moral evil of ethical relativism.
2. These limited options were at the root of the differences between some "mainstream" abortion rights and feminist groups, and feminist labor activists and antipoverty activists, in their reactions to the pivotal case of UAW v. Johnson Controls (1991). In reviewing this case, the U.S. Supreme Court found that "fetal protection policies," workplace regulations that barred fertile women but not fertile men from"risky" (and not coincidentally) lucrative work assignments, were discriminatory. Some labor and poverty-rights activists felt that by attacking the notion of fetal personhood, organizations such as NOW and NARAL were making it more difficult for working women to fight to receive compensation for desired pregnancies lost to workplace health hazards (personal communication to author by staff at the Massachusetts Coalition for Occupational Safety and Health and Boston Women of Color for Reproductive Freedom). For a concise synopsis and analysis of the case, see Cynthia Daniels, At Women's Expense: State Power and the Politics of Fetal Rights (Cambridge: Harvard University Press, 1993). Anthropological research on varying and culturally specific understandings of fetuses, newborns, and persons has enriched and enlivened discussion of fetal personhood by affording some autonomy from the U.S. context and its high stakes, even as cross-cultural studies are simultaneously explored as resources by U.S. feminists, who can invoke relativism and the wealth of human diversity to strike out at antichoice arguments built on culturally specific ideas about "nature," "natural order," and "scientific fact." References to practices of infanticide of twins or breech-birthed neonates among romanticized Others-practices defined internally as the elimination of nonlife or "abominations"-are entering the rhetorical stockpile of prochoice activists, in a fashion that should not go unexamined by feminists wary of contemporary colonialist turns. For example, discussion in one prominent women's health text of historical and anthropological perspectives reaches its climax by sensationally stating that "anthropologists reported one society in which the aborted fetus is fed to its would-have-been siblings." See Nada Scotland, "Contraception and Abortion: Challenges Now and for the Next Century," in Reframing Women's Health: Multidisciplinary Research and Practice, ed. Alice Dan (Thousand Oaks, Calif., and London: Sage, 1994), 143. In parallel fashion, such examples are appropriated by right-wing opponents of abortion rights to invoke a "slippery slope" in which concession of fetal life throws into question the visibility and value of the lives of children, elders, people with disabilities, and so forth, and to frame diversity of opinion and fetal personhood as part of a greater moral evil of ethical relativism.
3. The strategy of quietly modifying the health code, rather than frontally attacking the penal code, was initiated by an informal network of feminist lawyers, who-despite this temporary success-have not engaged in public debate on the topic of abortion Neighboring Puerto Rico-a colony of the United States where abortion has been legal since the landmark Roe v. Wade decision of 1973-did not see its first prochoice demonstration and the formation of political organizations explicitly and exclusively working for the preservation of abortion rights until 1989.
4. This figure is conservatively calculated by sociologist Denise Paiewonsky in her pioneering study of abortion in the Dominican Republic. See Denise Paiewonsky, El Aborto en la Republica Dominicana (Santa Domingo: CIPAF, 1988), 33.
5. The Council on Residency Education in Obstetrics and Gynecology provides residents in the United States with the option of proving their ability to place a patient in communication with an institution or clinician who is able to provide abortion, in lieu of learning the procedure themselves. See Carolyn Westhoff et al., "Residency Training in Contraception, Sterilization, and Abortion," Obstetrics and Gynecology 81 (February 1993): 311-14.
6. Paiewonsky, 71.
7. James Ferguson, Dominican Republic: Beyond the Lighthouse (London: Latin American Bureau, 1992), 94. It is beyond the scope of this article to trace the genesis of the Caribbean debt crisis and ongoing debate concerning its duration and long-term effects. For comprehensive overviews, see Carmen Diana Deere et al., In the Shadow of the Sun: Caribbean Development Alternatives and U.S. Policy (Boulder: Westview Press, 1990);
8. James Ferguson, Dominican Republic: Beyond the Lighthouse (London: Latin American Bureau, 1992), 94. It is beyond the scope of this article to trace the genesis of the Caribbean debt crisis and ongoing debate concerning its duration and long-term effects. For comprehensive overviews, see Carmen Diana Deere et al., In the Shadow of the Sun: Caribbean Development Alternatives and U.S. Policy (Boulder: Westview Press, 1990);
9. Jan Knippers Black, The Dominican Republic: Politics and Development in an Unsovereign State (Boston: Allen & Unwin, 1986), 55.
10. Linda Whiteford, "Contemporary Health Care and the Colonial and Neo-Colonial Experience: The Case of the Dominican Republic,Social Science and Medicine 35 (November 1992): 1215-23.
11. Instituto de Estudios de Poblacion y Desarrollo (IEDP), Les Servicios de salud por sectores en el Distrito National (Santa Domingo: IEDP, 1988), 6, 11, 14, 21.
12. Secretariat of Public Health and Assistance, National Mental Health Plan, (Santo Domingo: 1992), 6.
13. Cesar Mella Mejias, Salud y sociedad: Ponencias desde la universidad (Santo Domingo: Editora Universitaria, 1992), 133, 137-38.
14. Bernardo Defillo, comments on presentation by Armando Armenteros, Forum 10: El Ejercicio de la medicina en la Republica Dominicana, ed. Frank Moya Pons (Santo Domingo: Amigo del Hogar, 1983): 76-91.
15. Fernando Sanchez, "Condiciones de vida y trabajo de los profesionales del sector salud" ("Living and working conditions of health sector professionals"), AMD Gremial 13 (February-March 1988): 25-27.
16. See Connie Weil, "Variation in the Health Care Crisis," in Health and Health Care in Latin America during the Lost Decade: Insights for the 1990s, ed. Connie Weil and Joseph Scarpaci (Minneapolis: Minnesota Latin American Series, no. 3, 1992), 43; and Kaja Finkler, Physicians at Work, Patients in Pain: Biomedical Practice and Patient Response in Mexico (Boulder: Westview Press, 1991), 15.
17. See Connie Weil, "Variation in the Health Care Crisis," in Health and Health Care in Latin America during the Lost Decade: Insights for the 1990s, ed. Connie Weil and Joseph Scarpaci (Minneapolis: Minnesota Latin American Series, no. 3, 1992), 43; and Kaja Finkler, Physicians at Work, Patients in Pain: Biomedical Practice and Patient Response in Mexico (Boulder: Westview Press, 1991), 15.
18. Medical anthropologist Arthur Kleinman notes the tendency among healthcare professionals from "developing" countries to structure their healthcare systems along the lines of an "idealized model of professional care in technologically-advanced societies." See Arthur Kleinman, Patients and Healers in the Context of Culture (Berkeley: University of California Press, 1980), 32. In the case of the Dominican Republic, the contemporary public health and sanitation systems have evolved from institutions and practices set in place by the United States military during the 1916-24 U.S. occupation and have subsequently been shaped by the cold war ideological underpinnings of U.S. development programs. See Whiteford; and also her "A Question of Adequacy: Primary Health Care in the Dominican Republic," Social Science and Medicine 10 (January 1990): 221-26.
19. Medical anthropologist Arthur Kleinman notes the tendency among healthcare professionals from "developing" countries to structure their healthcare systems along the lines of an "idealized model of professional care in technologically-advanced societies." See Arthur Kleinman, Patients and Healers in the Context of Culture (Berkeley: University of California Press, 1980), 32. In the case of the Dominican Republic, the contemporary public health and sanitation systems have evolved from institutions and practices set in place by the United States military during the 1916-24 U.S. occupation and have subsequently been shaped by the cold war ideological underpinnings of U.S. development programs. See Whiteford; and also her "A Question of Adequacy: Primary Health Care in the Dominican Republic," Social Science and Medicine 10 (January 1990): 221-26.
20. Such robust rhetorical masculinization of the specialty took place despite the fairly even gender distribution of the ob/gyn residency corps.
21. In fact, hypertension is implicated as a cause in 12 percent of maternal deaths in the United States. Maternal hypertension complicated the course of between 12 and 16 percent of first pregnancies, and preeclampsia develops in approximately 5 percent of all pregnancies. See Gary Cunningham et al., Williams Obstetrics, 19th ed. (Norwalk, Conn.: Appleton & Lange, 1992), 4, 654, 764.
22. See also Linda Whiteford, "Child and Maternal Health and International Economic Policies," Social Science and Medicine 37 (December 1994): 1391-1400.
23. Abinader Fortunato, "Revelan muerte 15 recien nacidos hospital [Las Marias]" ("Deaths of fifteen newborns at Las Marias Hospital revealed"), El Sol, 8 Nov. 1990.
24. Defillo, 81.
25. As in much of Latin America, new and recently developed biomedical technologies are disproportionately to be found in private institutions affiliated with academic centers. See Gloria Coe and Ruth Hanft, "El Uso de la tecnologia en la atencion de la mujer: revision de la literatura," in Genero, mujer, y salud en las Americas, ed. Elsa Gomez Gomez (Washington, D.C.: Pan American Health Organization, 1993). Ironically, "undergraduate" Dominican medical students are more likely to work with fetal monitors, endoscopes, and sonograph machines than specialty residents. In the United States, the proliferation of fetal imaging technologies and the routinization of their use have had a great impact on the weight given to maternal concerns and desires in the management of pregnancy and labor, as well as public and professional discourse surrounding abortion. See Carol Stabile, "Shooting the Mother: Fetal Photography and the Politics of Disappearance," Camera Obscura 28 (January 1992): 179-206; and Emily Martin, The Woman in the Body: A Cultural Analysis of Reproduction (Boston: Beacon Press, 1987). Although I have not worked sufficiently in settings in the Dominican Republic where such technologies were regularly used, I would be loath to claim that their simple presence or absence determines practitioner perspectives on the fetus as patient.
26. As in much of Latin America, new and recently developed biomedical technologies are disproportionately to be found in private institutions affiliated with academic centers. See Gloria Coe and Ruth Hanft, "El Uso de la tecnologia en la atencion de la mujer: revision de la literatura," in Genero, mujer, y salud en las Americas, ed. Elsa Gomez Gomez (Washington, D.C.: Pan American Health Organization, 1993). Ironically, "undergraduate" Dominican medical students are more likely to work with fetal monitors, endoscopes, and sonograph machines than specialty residents. In the United States, the proliferation of fetal imaging technologies and the routinization of their use have had a great impact on the weight given to maternal concerns and desires in the management of pregnancy and labor, as well as public and professional discourse surrounding abortion. See Carol Stabile, "Shooting the Mother: Fetal Photography and the Politics of Disappearance," Camera Obscura 28 (January 1992): 179-206; and Emily Martin, The Woman in the Body: A Cultural Analysis of Reproduction (Boston: Beacon Press, 1987). Although I have not worked sufficiently in settings in the Dominican Republic where such technologies were regularly used, I would be loath to claim that their simple presence or absence determines practitioner perspectives on the fetus as patient.
27. As in much of Latin America, new and recently developed biomedical technologies are disproportionately to be found in private institutions affiliated with academic centers. See Gloria Coe and Ruth Hanft, "El Uso de la tecnologia en la atencion de la mujer: revision de la literatura," in Genero, mujer, y salud en las Americas, ed. Elsa Gomez Gomez (Washington, D.C.: Pan American Health Organization, 1993). Ironically, "undergraduate" Dominican medical students are more likely to work with fetal monitors, endoscopes, and sonograph machines than specialty residents. In the United States, the proliferation of fetal imaging technologies and the routinization of their use have had a great impact on the weight given to maternal concerns and desires in the management of pregnancy and labor, as well as public and professional discourse surrounding abortion. See Carol Stabile, "Shooting the Mother: Fetal Photography and the Politics of Disappearance," Camera Obscura 28 (January 1992): 179-206; and Emily Martin, The Woman in the Body: A Cultural Analysis of Reproduction (Boston: Beacon Press, 1987). Although I have not worked sufficiently in settings in the Dominican Republic where such technologies were regularly used, I would be loath to claim that their simple presence or absence determines practitioner perspectives on the fetus as patient.
28. Indeed, how can one help but recall Emily Martin's prediction (p. 64) that "if the doctor is managing the uterus as machine and the woman as laborer, is the baby seen as the 'product'?" In addition to Martin's insightful cultural analysis of baby as product, see Robbie Davis-Floyd's study of "obstetrical rituals" and their resolution of important cultural contradictions in contemporary America: "The Role of Obstetrical Rituals in the Resolution of Cultural Anomaly," Social Science and Medicine 31 (January 1990): 175-89. Davis-Floyd also observed frequent representation of the fetus and newborn as "products" of physician labor.
29. The Roman Catholic Church enjoys official recognition as the state religion, following a concordat signed by then-Dominican dictator Rafael Trujillo and Pope Pius XII in 1954.
30. My use of terms such as "deformed" or "genetically flawed" throughout this article is meant to reproduce physician discourse and the internal logics of a cultural system in which bodies, selves, and lives are differentially valued according to specific and culturally generated standards of appearance and behavior. It is not meant to reflect the "natural" or universal existence of biomedical or popular constructs of "disability." See Benedicte Ingstad and Susan Reynolds White, eds., Disability and Culture (Los Angeles and Berkeley: University of California Press, 1995), for anthropological perspectives on disabilities.
31. Desembarazo (de-pregnancy) is the customary term for a therapeutic abortion in Dominican maternity hospitals.
32. These clinics were very infrequently raided by Dominican authorities because they were profitable enterprises and thus able to pay for oversight and protection. As I shall later elaborate, this was not the case for midwives and "traditional" healers who assisted women in terminating pregnancies.
33. German Mora and Joao Yunes, "Mortalidad materna: Una tragedia ignorada," in Genera, mujer, y salud en las Americas, 78.
34. From unpublished 1987 and 1990 reports compiled by Drs. Santiago Acosta and Santos Ulloa of Hospital Infantil and Dr. Robert Reid's Centro Nacional de Investigaciones en Salud Materno-Infantil, titled, "Analisis, conclusiones, y recomendaciones de reunion tecnica sobre morbimortalidad materna e infecciosa." From 1981 to 1985, maternal mortality at Altagracia Hospital increased from 15 to 22 per 10,000 deliveries.
35. See Deere et al.
36. Residents took home the equivalent of U.S. $187 a month. In 1990, the annual inflation rate of 100.68 percent, coupled with the devaluation of the Dominican peso, caused salaries to decrease by 20.3 percent (data taken from the 1992 National Mental Health Care Plan).
37. Sue Fisher, In the Patient's Best Interest: Women and the Politics of Medical Decisions (New Brunswick: Rutgers University Press, 1986), 57.
38. Defillo, 81. I should clarify that in stating that Dominican physicians used to be "whiter" I am not alluding to the binary racial classification system prevalent in the United States but to a much more dynamic, fluid, and economically influenced system in effect in the Dominican Republic and the Latin Caribbean, which "lightens" individuals in proportion to their wealth and cultural Hispanicity. See H. Hoetink, The Dominican People, 1850-1900: Notes for a Historical Sociology (Baltimore: Johns Hopkins University Press, 1982); and "'Race' and Color in the Caribbean," in Caribbean Contours, ed. Sidney Mintz and Sally Price (Baltimore: Johns Hopkins University Press, 1985), 55-84.
39. Defillo, 81. I should clarify that in stating that Dominican physicians used to be "whiter" I am not alluding to the binary racial classification system prevalent in the United States but to a much more dynamic, fluid, and economically influenced system in effect in the Dominican Republic and the Latin Caribbean, which "lightens" individuals in proportion to their wealth and cultural Hispanicity. See H. Hoetink, The Dominican People, 1850-1900: Notes for a Historical Sociology (Baltimore: Johns Hopkins University Press, 1982); and "'Race' and Color in the Caribbean," in Caribbean Contours, ed. Sidney Mintz and Sally Price (Baltimore: Johns Hopkins University Press, 1985), 55-84.
40. A similar finding was made in a longitudinal study of gender roles and career satisfaction among obstetricians/gynecologists in the United States: "The investigators concluded that the professional work time of women physicians, but not of men, is affected negatively by home responsibilities." Nancy Kutner and Donna Brogan, "Gender Roles, Medical Practice Roles, and Ob-Gyn Career Choice: A Longitudinal Study," Women and Health 16, nos. 3-4 (1991): 99-117.
41. Anna Lowenhaupt Tsing, "Monster Stories: Women Charged with Perinatal Endangerment," in Uncertain Terms: Negotiating Gender in American Culture, ed. Faye Ginsburg and Anna Lowenhaupt Tsing (Boston: Beacon Press, 1990).
42. Teofilo Abreu, "Mucho cuidado con los remedios caseros!" ("Be careful with home remedies!"), Hoy, 14 May 1992; Antonio Caceres, "Dice Salud impedira funcionen curanderos" ("Says Health [Dept.] will keep healers from working"), Nacional, 11 May 1992; Candida Figuereo, "Salud Publica alerta sobre curanderos" ("Public Health warns about healers"), Ultima Hora, 15 May 1992; and Perfecta Martinez, "Curanderos azotan la region del Cibao" ("Healers scourge the Cibao region"), Ultima Hora, 21 May 1992. The campaigns to discredit folk healers and midwives are not unlike those described by Holly Matthews, in "Killing the Self-Help Tradition among African Americans: The Case of Lay Midwifery in North Carolina, 1912-1982," Southern Anthropological Society Proceedings 25 (1992): 64. "Physicians played upon ethnic and racial stereotypes to portray these midwives to the rest of the country as ignorant, backward, and superstitious, and arguing that they spread disease with their filthy customs and practices in attending birth and thus contributed to high levels of maternal and child mortality."
43. Teofilo Abreu, "Mucho cuidado con los remedios caseros!" ("Be careful with home remedies!"), Hoy, 14 May 1992; Antonio Caceres, "Dice Salud impedira funcionen curanderos" ("Says Health [Dept.] will keep healers from working"), Nacional, 11 May 1992; Candida Figuereo, "Salud Publica alerta sobre curanderos" ("Public Health warns about healers"), Ultima Hora, 15 May 1992; and Perfecta Martinez, "Curanderos azotan la region del Cibao" ("Healers scourge the Cibao region"), Ultima Hora, 21 May 1992. The campaigns to discredit folk healers and midwives are not unlike those described by Holly Matthews, in "Killing the Self-Help Tradition among African Americans: The Case of Lay Midwifery in North Carolina, 1912-1982," Southern Anthropological Society Proceedings 25 (1992): 64. "Physicians played upon ethnic and racial stereotypes to portray these midwives to the rest of the country as ignorant, backward, and superstitious, and arguing that they spread disease with their filthy customs and practices in attending birth and thus contributed to high levels of maternal and child mortality."
44. Teofilo Abreu, "Mucho cuidado con los remedios caseros!" ("Be careful with home remedies!"), Hoy, 14 May 1992; Antonio Caceres, "Dice Salud impedira funcionen curanderos" ("Says Health [Dept.] will keep healers from working"), Nacional, 11 May 1992; Candida Figuereo, "Salud Publica alerta sobre curanderos" ("Public Health warns about healers"), Ultima Hora, 15 May 1992; and Perfecta Martinez, "Curanderos azotan la region del Cibao" ("Healers scourge the Cibao region"), Ultima Hora, 21 May 1992. The campaigns to discredit folk healers and midwives are not unlike those described by Holly Matthews, in "Killing the Self-Help Tradition among African Americans: The Case of Lay Midwifery in North Carolina, 1912-1982," Southern Anthropological Society Proceedings 25 (1992): 64. "Physicians played upon ethnic and racial stereotypes to portray these midwives to the rest of the country as ignorant, backward, and superstitious, and arguing that they spread disease with their filthy customs and practices in attending birth and thus contributed to high levels of maternal and child mortality."
45. Teofilo Abreu, "Mucho cuidado con los remedios caseros!" ("Be careful with home remedies!"), Hoy, 14 May 1992; Antonio Caceres, "Dice Salud impedira funcionen curanderos" ("Says Health [Dept.] will keep healers from working"), Nacional, 11 May 1992; Candida Figuereo, "Salud Publica alerta sobre curanderos" ("Public Health warns about healers"), Ultima Hora, 15 May 1992; and Perfecta Martinez, "Curanderos azotan la region del Cibao" ("Healers scourge the Cibao region"), Ultima Hora, 21 May 1992. The campaigns to discredit folk healers and midwives are not unlike those described by Holly Matthews, in "Killing the Self-Help Tradition among African Americans: The Case of Lay Midwifery in North Carolina, 1912-1982," Southern Anthropological Society Proceedings 25 (1992): 64. "Physicians played upon ethnic and racial stereotypes to portray these midwives to the rest of the country as ignorant, backward, and superstitious, and arguing that they spread disease with their filthy customs and practices in attending birth and thus contributed to high levels of maternal and child mortality."
46. Teofilo Abreu, "Mucho cuidado con los remedios caseros!" ("Be careful with home remedies!"), Hoy, 14 May 1992; Antonio Caceres, "Dice Salud impedira funcionen curanderos" ("Says Health [Dept.] will keep healers from working"), Nacional, 11 May 1992; Candida Figuereo, "Salud Publica alerta sobre curanderos" ("Public Health warns about healers"), Ultima Hora, 15 May 1992; and Perfecta Martinez, "Curanderos azotan la region del Cibao" ("Healers scourge the Cibao region"), Ultima Hora, 21 May 1992. The campaigns to discredit folk healers and midwives are not unlike those described by Holly Matthews, in "Killing the Self-Help Tradition among African Americans: The Case of Lay Midwifery in North Carolina, 1912-1982," Southern Anthropological Society Proceedings 25 (1992): 64. "Physicians played upon ethnic and racial stereotypes to portray these midwives to the rest of the country as ignorant, backward, and superstitious, and arguing that they spread disease with their filthy customs and practices in attending birth and thus contributed to high levels of maternal and child mortality."
47. Martin; Barbara Ehrenreich, For Her Own Good: 150 Years of Experts' Advice to Women (New York: Doubleday, 1978); and Dorothy Smith, The Conceptual Practices of Power: A Feminist Sociology of Knowledge (Boston: Northeastern University Press, 1990).
48. Martin; Barbara Ehrenreich, For Her Own Good: 150 Years of Experts' Advice to Women (New York: Doubleday, 1978); and Dorothy Smith, The Conceptual Practices of Power: A Feminist Sociology of Knowledge (Boston: Northeastern University Press, 1990).
49. See Alan Klein, Sugarball: The American Game, the Dominican Dream (New Haven: Yale University Press, 1991).