Concepts of Health, Illness and Disease

A Comparative Perspective

Caroline Currer, Meg Stacey

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000323351
• Edition: 1
• Topic: Medizin
• Subtopic: Krankheiten & Allergien

Both health care practitioners and health planners are beginning to recognize the importance of differences between lay and professional concepts of health and illness. The editors of this volume, having themselves worked in this field for many years, have selected and brought together writings by distinguished scholars from Britain, France, the United States, Germany and Poland. What impresses most is the range of problems synthesized from a genuinely international and interdisciplinary perspective. No reader can fail to be fascinated by the often peculiar ways in which different societies have tried to cope with the existential questions of health and illness.

MEG STACEY

1 Concepts of Health and Illness and the Division of Labour in Health Care¹

The first of the four papers which, in differing ways, attempt an overview of the field, is by Meg Stacey. She is interested in relating concepts of health and illness to the structure of the society in which they are found, particularly to the division of labour, the position of members, their life experiences and their material and psycho-social interests. She uses numerous examples of field studies to work out her argument, seeing the propositions as ones which can be found at the micro level and related to the macro. She suggests that the dominant concepts are those of the successful and powerful, whose interests they serve.

An initial statement of assumptions enables the reader to critically consider starting points which are often not made explicit, and to question the extent to which these same assumptions might or might not underlie the work of other authors. The bulk of the paper is then taken up with a review of the empirical work of others within the suggested framework, thereby demonstrating its value as a way of approaching this complex field and of arranging findings that arise from a variety of disciplines and may be quite disparate. The work referred to includes that of other contributors to this volume, but also ranges far wider, drawing in selections that we should have liked to have included had space allowed, as well as work more tangential to our central theme but which relates to it. Thus the paper offers a fitting way into this collection overall; a framework which focuses on social rather than cultural factors influencing concepts (thereby reflecting its author's interests and background) and which indicates a fruitful way in which the increasing and varied contributions to this field might be arranged and understood.

Eds.

1. An earlier version of this paper was presented at the workshop on lay concepts of health and illness organised by Or Bert Tax and his colleagues at Nijmegen, Netherlands, in July 1984.

My interest in concepts of health and illness has to do with the way they relate to the division of labour. The fully fledged analysis which I would like to see would be one in which the healers, where they exist as specialists, would be located in the structure of the society to which they belong; located also in the conflicts within that society which are associated with the form of the state (of whatever type), the mode of production, the social class and gender orders and other social relationships. These data would be related to the health and illness concepts to which healers and their clients subscribe, and the concepts themselves would be related to the cosmologies and ideologies of die society.

The evidence available for such an enterprise is increasing but remains fragmentary. In any case, it is too vast for any one person to contemplate. Within that, what I have been trying to do is to illustrate some parts of what such an enterprise might look like. My work falls into three sections, each of which represent different avenues of exploration, and for each of which there is some empirical data available. These are:

1. Dominant conceptions and the division of labour in a society.
2. Members' social position, their life experiences and the concepts they select.
3. Concepts and members' material and psycho-social interests.

In this paper I shall mainly concentrate on aspects of 2 and 3.

My analyses are predicated upon certain initial assumptions. The first is that for the purposes of investigation I take all value, belief and knowledge systems to be of equal importance and validity; initially they should be judged on their own terms and within their own logic. Such a conceptual framework is essential for systematic analysis at both theoretical and empirical levels.² This means that variations in concepts of health and illness cannot be viewed merely as exotica of by egone or fading societies, or curious residual remains among eccentric groups or individuals in contemporary society, left over perhaps from the witches of old.

2. It is, of course, a different enterprise within any one society (one, say, in which biomedicine is accepted as the major curative cosmology) to assess the extent to which lay concepts impede or facilitate the proper use of healing services provided.

Allan Young (1976a) has addressed the question of how to define the field of interest of medical anthropology without using a Western medical paradigm, Robin Horton (1970, 1971) showed that there were not the great differences between Western scientific thought and African thinking that Western scientists had believed. The quest for unity underlying apparent diversity, for simplicity underlying apparent disorder, for regularity underlying anomaly, is apparently universal (Horton, 1970:342). All people at all times try to make sense of what otherwise appears as confusion around them. Theory, Horton argues, replaces common sense; so does mystical thinking replace common sense; so, we might add, does lay logic seek to replace common sense. Mystical thinking (and lay logic) are kinds of theories. Processes of abstraction, analysis and reintegration are present in all three. The differences between African mystical thought and Western scientific medicine are described by Horton as the open and closed predicaments. Mystical thinking is closed; it cannot imagine any alternative and it does not permit thinking about alternatives. Western thought is open; it is part of the scientific process that the scientist should always be looking for explanations beyond those she/he presently accepts and should be prepared to have propositions disproved. There are limitations to Horton's theory, especially with regard to the openness in practice of Western scientific thought. The point I wish to make is that Robin Horton and Allan Young both grant equal status to all bodies of knowledge, differentiating them not on criteria of their correctness or supposed efficacy but in terms of their concepts. Young (1976b) uses the terms 'systematising theory' and 'everyday thinking' to describe them where the former strives consciously for coherence and is confined to categories of culturally defined specialists who restrict their use of systematised thinking to their own professional arena and interests.

My second assumption is that all concepts of health and illness, like all healing systems, are social constructions which relate to their historically specific time or period. Powerful and pervasive systems such as biomedicine I include in this just as much as more fragmentary and localised ones. My third assumption is linked with this, namely that concepts are not neutral, they are associated with actions taken and with given sets of social relations. In this I include allegedly neutral science. It follows, of course, that social scientists, like others who seek to produce knowledge, are also creatures of their time and place. They, like others, are therefore likely to find that their creations are used in the ongoing struggle of interests in their society.

Finally, I assume the unity of the human species (cf. Ginsberg, 1961:206) such that I take all human beings to be constructing their notions of health and illness and how to handle these phenomena with reference to an essentially similar biological base. Over and above this underlying humanness there are of course great variations from one society to another in the threats to the biological organism associated with such things as climate and food supply, as well as social and economic organisation. Within any one society, individuals also have different empirical biological experiences of health and illness. What problems there are to resolve on the health and illness front therefore vary. This may well influence how members conceive them. Nevertheless, all peoples have essentially the same apparatus of mind and body with which to handle their problems.

Dominant Conceptions and the Societies in Which They are Found

Before turning to the main themes of this paper I should perhaps give some indication of my search for reasons behind the variations in dominant concepts and the societies in which they are found. In the longer work (Stacey, forthcoming) I review some examples of societies with varying modes of the division of labour, taking the Gnau (Lewis, 1975, 1976, 1980, and see extracts below, Ch. 6), the Amhara (Young, 1976b, and below, Ch. 7), and the Manus (Schwartz, 1969) as examples, using Allan Young's (1976b) notion of internalising systems and Arthur Kleinman's (1978b, and below, Ch. 3) notion of the three domains of popular, folk and professional healing systems. Here I note that the Gnau have little division of labour in their society, no specialist healers and that their notions of causality and the process of illness and misfortune fit them into Young's externalising category. Kleinman's three divisions do not apply to them. However, I note also that there is a sexual division of labour, that men more often take an active healing role than women and that there is some differentiation between women's and men's health and illness experience. The Amhara, on the other hand, have what Young (1976b) calls an incomplete internalising system; healing is only partially professional and both 'physiological' and 'aetiological' explanations are found. There is no one theory of health, illness and treatment; literate and oral traditions exist side by side and have done so for two millenia. There is considerable division of labour in Amhara health care, and healers are distinguished by their healing activities. Some healers are highly trained and differentiated specialists; others are undifferentiated in their everyday lives from other workers.

The Gnau and Amhara, like many other peoples, do not distinguish sharply between illness and a wider range of misfortune. I note that the Manus (Schwartz, 1969) accept biomedicine but take it to be a low-level theory with limited explanatory powers.

I then look at the historical development of biomedicine in Europe in association with the changing division of labour in capitalist society and pay attention to the division of labour in public domain, industry, state and market-place, within the domestic domain in the patriarchal family and between the public and private domains. This historical background cannot be explored here and must be taken as understood. There are two points, however, which should perhaps be made.

The first has been made by Steven Feierman (1979) and is worth repeating. In Tudor and Stuart England there was a variety of healing systems. Within two hundred years biomedicine had become dominant. This is a somewhat remarkable history which has been explored in a variety of ways. See, for example, Ivan Waddington (1985) and Meg Stacey (forthcoming).

The second is a point which Claudine Herzlich (1973), among others, has made. As she says, there are two sets of theories dealing with health and illness: those 'based on the objective examination of physical signs of disease and theories which view health and illness as modes of relationships — equilibrium and disequilibrium — between [people] and [their] environment, involving human factors, ecological aspects and social structures' (1973: 2). This distinction is similar to Allan Young's internalising and externalising systems (see below, Ch. 7). Claudine Herzlich reminds us how, in the course of the centuries in Europe after Hippocrates, the 'body orientation' became dominant, and anatomy and physiology developed from the sixteenth century; with exploration came interest in 'strange' diseases and the development of a geography of disease. This was linked with a recognition of the connection between disease and social conditions. But when Pasteur's theories triumphed, 'although the existence of geographical factors could not be denied — there really is a geography of disease — they appeared unimportant, and research became almost wholly concerned with the study of the microbic agent itself (1973: 3). Recently, as she points out, there has been a reaction against an exclusively ontological view of illness, and attention has been paid to psychological factors and thus to psychosomatic medicine, to cultural relativity of concepts of health and illness and to illness behaviour. In her work with Pathan women, Caroline Currer (see below, Ch. 9) found that their conceptualisation not only of what it is to be ill but how one does and should live, varied so much from the Euro-American that well-validated psychological scales could not be used in the manner intended. The ways in which these developments have taken place in Europe and America over the centuries is further developed in the work Claudine Herzlich has done with Janine Pierret — presented in Malades d'hier, malades d'aujourdhui (1984) — drawing upon diaries, medical writings and many other sources (an extract appears as Ch. 4. below: see also Herzlich and Pierret. 1985).

Michel Foucault (1973) has demonstrated how, within that concentration on the body that began in the sixteenth century, crucial changes in medical conceptualisation took place around the turn of the nineteenth century: there developed the new medical 'gaze', itself linked with the development of bedside medicine and the dissection of the human body, which broke old taboos and changed the way of looking and of what was seen. The developments, occurring at a particular stage of capitalism and of the class structure, changed the notion of what constitutes disease and led, not only to a new classification of disease, but also to the foundation of modern clinical biomedicine, constituted of new forms of medical knowledge, practices and institutions. David Armstrong (1983) has taken this work forward in an analysis of the changes of medical knowledge in the twentieth century. Neither Foucault nor Armstrong, however, recognise the importance of the gender order and the masculine bias, not only in the division of biomedical labour but also in the biomedical knowledge itself (see Graham and Oakley, Ch. 5, below, for a contemporary example).

With regard to contemporary societies dominated by biomedicine, R. G. A. Williams (1983) has suggested that there may be resemblances of a fundamental kind across cultures and societies in the ways in which all peoples conceive of health and illness. He suggests this after comparing his findings among older people of all classes in Aberdeen with those of Claudine Herzlich's (1973) middle-class Parisians and Normans.

In the 1960s Herzlich had asked her French sample how they thought about health and illness. She was interested in their concepts in terms of Durkheim's social representations (representations sociales). Later Alphonse d'Houtaud (d'Houtaud and Field, 1984; and below, Ch. 12), inspired by Herzlich's study, examined the health beliefs of people in Lorraine who were presenting themselves for a health check-up. More recently again, Williams has applied these ideas to populations of the elderly in Scotland. It was a comparison of his findings with those of others, including Herzlich and d'Houtaud, that led Williams to think about similarities. This is certainly an important idea to pursue, but it is the variation in the French compared with the British concepts which interest me, bearing in mind that biomedicine is dominant in both countries and its development in France greatly influenced its development in England. The notion of health as a balance, as a state of equilibrium is much stronger in France than it is in Scotland. Nevertheless, in d'Houtaud's (d'Houtaud and Field, 1984) study the working-class French of Lorraine more often than middle-class Parisians used the notion of fit or able to work so common among the elderly Scottish and among Kristian Pollock's (1984) Nottingham respondents. A second difference relates to the way in which fatigue or weakness is conceptualised. In both samples these concepts are separated from sickness, but the French appear to make more of the upset to equilibrium associated with fatigue and to consult more for 'psychosomatic' reasons. The Scots, on the other hand, stress the inappropriateness of adopting the sick role on grounds of 'weakness'. Williams suggests that this has to do with the 'disease-centred conception of illness, and the fear of hypochondria which goes with it' (202). One could add to this the importance in that generation and nation of the Protestant work ethic.

Williams suggests also that the fee-for-service system of payment compared with the capitation fee in Britain may give comparatively more power to middle-class French patients vis-à-vis their doctors and so to the popular culture. Cecil Helman (1978; and below, pp. 225-7) showed differences between his older and younger patients in what was a 'cold' to be 'fed' and dealt with by self-treatment and a 'fever' to be 'starved' and reported to the doctor for treatment. Helman suggests that between his two age groups two changes had taken place. One was the introduction of antibiotics and the other the establishment of the National Health Service (NHS), with health care free at the point of delivery. I have suggested a similar explanation for the lack of moral reasons for their illness or accident offered by my third-year sociology students, compared with Irving Zola's (1975) undergraduates when asked to explain an illness or an accident to a child.

Jeremy Seabrook's (1973; and see extracts below, Ch. 10) early-twentieth-century Northamptonshire bootworkers and their families had little access to doctors. Their explanations were full of morality, and an elaborate cosmology informed their attempts to stave off illness or disaster. When access to doctors is easy and does not require immediate cash payment, such preventive systems may be less necessary. However, the authority of the doctor increases in these circumstances. My data, collected from students of varied class backgrounds, but biased to the middle class and including some mature women and men, span the past ten years. In that time the one moral injunction which was frequently referred to was 'you must go to the hospital/doctor'. This injunction has become more frequent over the decade. These changes are consistent with Jocelyn Cornwell's (1...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Tables and Figures
• Acknowledgments
• Introduction
• 1. Concepts of Health and Illness and the Division of Labour in Health Care
• 2. Concepts and a Model for the Comparison of Medical Systems as Cultural Systems
• 3. The Conceptual Determination (Uberformung) of Individual and Collective Experiences of Illness
• 4. Illness: From Causes to Meaning
• 5. Competing Ideologies of Reproduction: Medical and Maternal Perspective on Pregnancy
• 6. Concepts of Health and Illness in a Sepik Society
• 7. Internalising and Externalising Medical Belief Systems: An Ethiopian Example
• 8. Reactions of Samoan Burn Patients and Families to Severe Burns
• 9. Concepts of Mental Well- and Ill-Being: The Case of Pathan Mothers in Britain
• 10. The Unprivileged: A Hundred Years of Their Ideas about Health and Illness
• 11. 'Feed a Cold, Starve a Fever': Folk Models of Infection in an English Suburban Community, and Their Relation to Medical Treatment
• 12. New Research on the Image of Health
• 13. Concepts of Illness Causation and Responsibility: Some Preliminary Data from a Sample of Working-Class Mothers
• 14. Two Basic Types of Medical Orientation
• Conclusion
• Bibliography
• About the Contributors
• Index