Health and Disease

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HEALTH AND DISEASE

Why care about the precise definitions of the words health, disease, and illness? Their meanings seem self-evident: Health is the absence of disease, illness the experience of disease. However the multiple dimensions of these concepts, their moral underpinnings, and the purposes for which they are used are enormously complex, especially in a technological society strongly oriented toward the production of health.

Health and disease are more than just medical terms; they have social, political, moral, and economic dimensions. For example, a pharmaceutical company may advertise its new compound as the cure for a heretofore-unnamed disease such as erectile dysfunction or attention deficit disorder (ADD). Medical or disability coverage is granted or denied based on sociopolitical interpretations of what constitutes a disease or disability. A couple decides to use in vitro fertilization and preimplantation genetic screening to avoid creating a baby with a genetic disease or one who will be a carrier of a diseased gene. Or perhaps a soft drink producer enhances sales by touting the benefits of its new and improved healthier beverages. Professional codes of ethics commonly commit engineers to protect public safety, health, and welfare. The concepts of health and disease are invoked in various ways, for purposes weighty and mundane.

Indeed health has been construed not simply as the absence of disease (whatever that is), but much more. In the preamble to its constitution, the World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being not merely the absence of disease or infirmity." Such statements rely on medico-moral presuppositions of what a disease actually is, how and which diseases ought to be treated, and ultimately on visions of what it means to live the good life.

Recognition of the complexity of the concepts of health and disease has stimulated scholarship in the fields of history and philosophy of medicine, sociology of medicine, and the medicalization of deviance, as well as crucially important policy developments in managed care and resource allocation. Philosophical questions range from clarifying the ontological status of disease (What is a disease?) to understanding particular conditions and the meaning of being diseased. The social sciences, including medical sociology and anthropology, examine the extent to which disease is a value-laden concept shaped and socially constructed. How do power relations influence what is considered to be normal and healthy or abnormal and diseased? On the level of individual experience, still other questions emerge: What is the personal meaning of being healthy or sick? At what point, if any, are the sick blameworthy for their illnesses? What role ought a sick person play in society? How does stigma affect the sick? More broadly framed questions regarding matters of policy ask what responsibilities society has to care for those who are diseased or ill.

Different responses to such questions are associated with diverse historical and philosophical approaches to health and disease. Sociological contributions to the debate and their policy implications also deserve consideration. This simple conceptual breakdown is appropriate for present purposes, but it is important to note that a more holistic picture requires interdisciplinary dialogue.

Historical Sketch

The concepts of health and disease were foundational to the ancient medical arts and bound up with distinct philosophical perspectives. To explain illness or symptoms of disease, as well as to cure the sick, pre-Socratic philosophers and ancient Greek physicians in the Hippocratic tradition (c. 400 b.c.e.) developed a basic explanation of health as balance (isonomia). The balance of the four humors—black and yellow bile, phlegm, and blood—in conjunction with environmental and temporal factors was central to the formalized model of health created by the Greek physician Galen (130–199 c.e.). A rudimentary nosology (classification of diseases) was developed around the imbalance of the humors.

Galen's humoral model persisted through the Middle Ages when it was augmented by Christian ideals of salvific suffering. Although the link between disease and sin was not a new development, moral dimensions of health and disease were described in terms of tests from God, punishment for sin, or demonic possession (Gunderman 2000). Toward the end of the Middle Ages, a new model was espoused by the physician-philosopher Paracelsus (Philippus Aureolus Theophrastus Bombastus von Hohenheim 1493–1541) indicating three elemental components (salt, mercury, and sulfur) as critical to healthy physiology. Paracelsus went on to claim that diseases were not simply internal imbalances, but rather resulted from autonomous entities "springing from the body" (Vichow 1981, p. 192). The ontologists—those thinkers who viewed diseases as actual entities—find the roots of their approach in the work of Paracelsus.

Modern concepts of health and disease (and the practice of scientific medicine itself) are grounded in Cartesian dualism. René Descartes (1596–1650) separated the mind and the body, and described the body as a set of parts working together according to mechanical rules. Because disease was the malfunctioning of the bodily machine, treatment consisted of diagnosing the malfunction and repairing the body, bringing it back to normal functioning (von Engelhardt 1995).

Over the next few centuries, the locus of disease shifted from the macroscopic to the microscopic, and eventually to the molecular. Contributions by the anatomists at the University of Padua—in particular Giovanni Morgagni (1682–1771)—opened discussion on pathophysiology and etiology through postmortem dissections of diseased organs. Marie Francis Xavier Bichat (1771–1802) explained the origins of disease in terms of histopathology—disease in tissues. On the cellular level, Rudolf Virchow (1821–1902) synthesized breakthroughs in bacteriology and microbiology and described mycotic diseases in terms of ens morbi and causa morbi (a being with a cause), and as a disruption in interrelated cellular territories which, in turn, compound and spread the disease process. With the rediscovery of Mendelian genetics in the late-nineteenth century, inheritance factors were singled out as disease entities that caused such disorders as Huntingdon's Disease and sickle cell anemia. Indeed sickle cell anemia was the first modern genetic disease identified as such by Linus Pauling.

In contrast to the ontologists were the nomino-physiologists, such as François-Joseph-Victor Broussais (1772–1838), who opposed the idea that diseases were actual entities. Such entity-based nosologies, he claimed, were not classifications of disease entities but rather were driven by a physician's instrumental and pragmatic need to diagnose or prognosticate. Claude Bernard (1813–1878) emphasized the need for clinical experimentation and observation in describing diseases. Through his diverse research projects, particularly studies of digestion, glycogen function, and vasoconstriction and dilation, Bernard developed physiological models that emphasized homeostasis and feedback loops in the regulation and maintenance of health. So too, the American physiologist Walter Cannon (1871–1945), in The Wisdom of the Body (1932), described health and disease in homeostatic terms.

Philosophical Trends

Philosophers of medicine and science began a more formal analysis of the concepts of health and disease during the first half of the twentieth century. The medical history and epistemology of Georges Canguilhem (1904–1995) and his student Michel Foucault (1926–1984) stimulated a renewed discussion of the normal and the pathological. Eventually a cannon of philosophical writings on the concepts of health and disease was formed during the period 1960 to 1981, a development that was driven in part by the birth and development of bioethics and its need for definitional precision for basic medical concepts (Caplan et al. 1981).

During the 1970s, a conceptual dichotomy in philosophy of medicine developed as new accounts of the status of disease took two tracks. First, reminiscent of the earliest philosophical constructions of disease, various versions of naturalism reemerged. Naturalistic accounts explained disease as deviations in natural form and function. As such, a disease was described as an entity or causal factor of that deviation independent of social norms or cultural values. This perspective is sometimes referred to as nonnormativism (Caplan 1988). Christopher Boorse (1975) presented the quintessential nonnormative position by referring to an objective biological framework that guides the identification and diagnosis of disease:

[B]ehind this conceptual framework of medical practice stands an autonomous framework of medical theory, a body of doctrine that describes the functioning of a healthy body, classifies various deviations from such functioning as diseases, predicts their behavior under various forms of treatment, etc. This theoretical corpus looks in every way continuous with theory in biology and the other natural sciences, and I believe it to be value-free. (Boorse 1975, p. 55.)

In contrast, normativist philosophers point to the value-laden nature of disease constructions, eschewing the possibility that natural is definable and that diseases are value-free. These scholars directly counter the Boorsian model by pointing to research in philosophy and sociology of science that described science and medicine as social endeavors. Because of this social embeddedness, an autonomous and value-free framework of medico-biological theory does not exist independently of values. (Kuhn 1962, Longino 1990, Engelhardt 1981). Arthur Caplan, H. Tristam Engelhardt, and Joseph Margolis are among those who write a defense of moderate normativism. Caplan (1981) points out that, while some objective criteria for defining disease exist, nonnormativism as characterized by Boorse is fraught with conceptual inadequacies. Some conditions generally considered to be normal or natural (e.g., the common cold, dental plaque, acne, and others) are disvalued, while others considered to be abnormal may be valued (for example, dysfunctional gonads in a person who does not wish to reproduce). Margolis (1976) claimed that while certain biological functions may be conceived in universal terms, the actual concept necessarily reflects the state of the technology, social explanations, division of labor, and the environmental conditions of a given population. Engelhardt (1974) describes the pragmatic and value-laden nature of the concept of disease particularly in his historical exposition of the disease of masturbation.

The philosophical debate about the nature of somatic disease spills over into the analysis of mental health and disease. With the rise of scientific medicine, the prevailing model of psychiatric illness became biologically based. Mental illness was considered similar to other somatic diseases, rooted in a dysfunction, or even an ens morbus. This model was vigorously challenged by physician George Engel (1913–1999) as being overly reductionistic; he offered his own biopsychosocial model to account for the role of relationships and society in health and disease (Engel 1977). Thomas Szasz's The Myth of Mental Illness (1961) attacked the notion that mental illness was a disease of the brain or that mental illness existed at all. Szasz claimed that the notion of mental illness was a way to subjugate dissidents of the community's collective ethos or assuage sick individuals of their responsibilities.

In the early-twenty-first century, genetic technology and medicine as well as the results of the Human Genome Project added another level of complexity to analyses of health and disease. A greater understanding of epigenetics and the complexities of gene-environment interactions show it is difficult to identify the genetic causes of diseases that are outside the basic Mendelian framework. Nonetheless health and disease are increasingly described in genetic terms. Reification of genetic anomalies as being diseases has raised the very real possibility that all people are diseased in some way (Jüngst 2000).

Sociological Perspectives and the Medicalization of Deviance

Philosophical debates about health and disease as normative concepts grade into descriptive analyses of how society constructs, describes, and reacts to the realities of health, disease, and illness. Talcott Parsons (1902–1979) explained the concepts of health and illness as manifestations of certain role-types.

In framing the sick role, Parsons took the first step in describing illness as a form of deviant behavior legitimized by the medical institution (Bosk 1995). The sick role is characterized first by an exemption from social duties, exculpating patients for their illness. Parsons described the physician-patient relationship as analogous to the relationship between a child and parent in which the patient follows doctor's orders in a team effort directed toward the patient's wellness. Often this is a form of social control because a sick person needs to enlist the help of persons who are not sick and their therapeutic agencies.

Some social scientists have theorized the construction of disease emerges out of power structures, sanctioned under the guise of medical objectivity. Looking back in history, an early example of this dynamic was the description of drapetomania—a disease of slaves that caused them to try to run away. Physician Samuel Cartwright (1793–1868) presented an account of this disease and potential cures, which included, first, kind treatment, but later various forms of severe bondage and punishment. Since then, health and disease have sometimes been hijacked in the name of ideology or the betterment of common good. In hindsight these instances are obvious, for example, eugenics movements during the early-twentieth century in the United States and in Germany in which diseased individuals, their families, or their entire race were treated (Caplan 1992b). In contrast to these more egregious cases, some social scientists suggest more insidious forms of disease construction have occurred through the medicalization of deviant behavior.

Peter Conrad (1975, 2000) describes how hyperkinesis—now called attention deficit and hyperactivity disorder (ADHD)—became a disease. Conrad explains that, with the invention of the stimulant Ritalin and observation of its paradoxical effect on children, the manufacturer, CIBA, sought to market the compound to parents and teachers of unruly children. The cure preceded the disease. The administration of a drug that reigned in nonconformist children strengthened the status quo: educational systems not equipped to accommodate certain children and parents released from blame for their children's behavior. Similar examples can be found in feminist accounts of the social construction and medicalization of menopause and premenstrual syndrome (McCrea 1983, Richardson 1995).

Labeling theorists, such as Howard Becker (1928), describe the actions of moral entrepreneurs who create and enforce social rules. In medicine, moral entrepreneurs may be physicians who ascribe the label diseased to those who break with accepted conventions, thus suppressing or stripping them of opportunity, thereby expanding their own domain of professional influence (Becker 1963, Pfohl 1977, Bosk 1995).

As a result of labeling, stigma is often closely associated with disease. In certain cases, sick people remain closeted because of the stigma of their illness. Norma Ware (1992) offers the example of chronic fatigue syndrome. Delegitimation of the subjective experience of illness leads to further suffering arising from the stigma of the disorder, the alienation resulting from a decision to keep the illness secret, and the shame of being wrong in one's own definition of reality.

Broad Policy Implications

The ways in which the concepts of health and disease are framed have significant impact on health policy. In particular, defining what constitutes the appropriate level of medical care provided by a just society has been difficult to determine.

Several nosological frameworks driving insurance schedules and socialized coverage plans have been espoused over the years. Norman Daniels, in Just Health Care (1994), proposes a policy framework based not on definitions of disease or health but on species-typical functioning. Daniels proposes that normal functioning is an important baseline not because it is natural, but because it is a convenient point at which to determine what society should owe to its members. Indeed a consensus of what society ought to give to all its members has been elusive precisely because a common framework of health and disease has been impossible to construct.

Equally important to providing care and treatment of disease is the scientific quest to prevent and cure disease. Operational definitions of health and disease ground biomedical research priorities in government and private funding agencies. The National Institutes of Health (NIH) determine research priorities based on a broad range of criteria related to severity of diseases, epidemiological evidence, cost-benefit analyses, as well as projects that offer promises and opportunities, and interest groups/patient lobbying. Investment in research and development and biotechnology, as well as in allied fields of technology, rest on the social framework and disciplinary matrix within which technicians work. As such core concepts such as health and disease have a profound, albeit overlooked, influence on the trajectory of important advancements in technology.

The concepts of health and disease underlie decisions to fund basic bench research through clinical biomedical research and public health initiatives. Clearly a robust understanding of the complexities of these concepts is crucial for policymakers, clinicians, and patients alike.

DOMINIC A. SISTI

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INTERNET RESOURCE

World Health Organization. (1948). "Preamble to the Constitution." Available from http://whqlibdoc.who.int/hist/official_records/constitution.pdf. WHO Constitution adopted by the International Health Conference, New York, June 19–22, 1946; signed on July 22, 1946 by the representatives of sixty-one states and entered into force on April 7, 1948. Can also be found in the Official Records of the World Health Organization, no. 2, p. 100.

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