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4

The Invention and
Elimination of Disease

   

   The French Revolution gave birth to two great myths: one, that physicians could replace the clergy; the other, that with political change society would return to a state of original health.1 Sickness became a public affair. In the name of progress, it has now ceased to be the concern of those who are ill.2

   For several months in 1792, the National Assembly in Paris tried to decide how to replace those physicians who profited from care of the sick with a therapeutic bureaucracy designed to manage an evil that was destined to disappear with the advent of equality, freedom, and fraternity. The new priesthood was to be financed by funds expropriated from the Church. It was to guide the nation in a militant conversion to healthy living which would make medical sick-care less necessary. Each family would again be able to take care of its members, and each village to provide for the sick who were without relatives. A national health service would be in charge of health care and would supervise the enactment of dietary laws and of statutes compelling citizens to use their new freedoms for frugal living and wholesome pleasures. Medical officers would supervise the compliance of the citizenry, and medical magistrates would preside over health tribunals to guard against charlatans and exploiters.

   Even more radical were the proposals from a subcommittee for the elimination of beggary. In content and style they are similar to Red Guard and Black Panther manifestos demanding that control over health be returned to the people. Primary care, it was asserted, belongs only to the neighborhood. Public funds for sick-care are best used to supplement the income of the afflicted. If hospitals are needed, they should be specialized: for the aged, the incurable, the mad, or foundlings. Sickness is a symptom of political corruption and will be eliminated when the government is cleaned up.

   The identification of hospitals with pestholes was current and easy to explain. They had appeared under Christian auspices in late antiquity as dormitories for travelers, vagrants, and derelicts. Physicians began to visit hospitals regularly at the time of the crusades, following the example of the Arabs.3 During the late Middle Ages, as charitable institutions for the custody of the destitute, they became part and parcel of urban architecture.4 Until the late eighteenth century the trip to the hospital was taken, typically, with no hope of return.5 Nobody went to a hospital to restore his health. The sick, the mad, the crippled, epileptics, incurables, foundlings, and recent amputees of all ages and both sexes were jumbled together;6 amputations were performed in the corridors between the beds. Inmates were given some food, chaplains and pious lay folk came to offer consolation, and doctors made charity visits. The cost of remedies made up less than 3 percent of the meager budget. More than half went for the hospital soup; the nuns could get along on a pittance. Like prisons, hospitals were considered a last resort;7 nobody thought of them as tools for administering therapy to improve the inmates.8

   Logically, some extremists went beyond the recommendations made by the committee on beggary. Some demanded the outright abolition of all hospitals, saying that they "are inevitably places for the aggregation of the sick and breed misery while they stigmatize the patient. If a society continues to need hospitals, this is a sign that its revolution has failed."9

   A misunderstanding of Rousseau vibrates in this desire to restore sickness to its "natural state,"10 to bring society back to "wild sickness," which is self-limiting and can be borne with virtue and style and cared for in the homes of the poor, just as previously the sicknesses of the rich had been taken care of. Sickness becomes complex, untreatable, and unbearable only when exploitation breaks up the family,11 and it becomes malignant and demeaning only with the advent of urbanization and civilization. For Rousseau's followers the sickness seen in hospitals was man-made, like all forms of social injustice, and it thrived among the self-indulgent and those whom they had impoverished. "In the hospital, sickness is totally corrupted; it turns into 'prison fever' characterized by spasms, fever, indigestion, pale urine, depressed respiration, and ultimately leads to death: if not on the eighth or eleventh day, then on the thirteenth." 12 It is this kind of language that made medicine first become a political issue. The plans to engineer a society into health began with the call for a social reconstruction that would eliminate the ills of civilization. What Dubos has called "the mirage of health" began as a political program.

   In the public rhetoric of the 1790s, the idea of using biomedical interventions on people or on their environment was totally absent. Only with the Restoration was the task of eliminating sickness turned over to the medical profession. After the Congress of Vienna, hospitals proliferated and medical schools boomed.13 So did the discovery of diseases. Illness was still primarily nontechnical. In 1770, general practice knew of little besides the plague and the pox,14 but by 1860 even the ordinary citizen recognized the medical names of a dozen diseases. The sudden emergence of the doctor as savior and miracle worker was due not to the proven efficacy of new techniques but to the need for a magical ritual that would lend credibility to a pursuit at which a political revolution had failed. If "sickness" and "health" were to lay claim to public resources, then these concepts had to be made operational. Ailments had to be turned into objective diseases that infested mankind, could be transplanted and cultivated in the laboratory, and could be fitted into wards, records, budgets, and museums. Disease was thus accommodated to administrative management; one branch of the elite was entrusted by the dominant class with autonomy in its control and elimination. The object of medical treatment was defined by a new, though submerged, political ideology and acquired the status of an entity that existed quite separately from both doctor and patient.15

   We tend to forget how recently disease entities were born. In the mid-nineteenth century, a saying attributed to Hippocrates was still quoted with approval: "You can discover no weight, no form nor calculation to which to refer your judgment of health and sickness. In the medical arts there exists no certainty except in the physician's senses." Sickness was still personal suffering in the mirror of the doctor's vision.16 The transformation of this medical portrait into a clinical entity represents an event in medicine that corresponds to the achievement of Copernicus in astronomy: man was catapulted and estranged from the center of his universe. Job became Prometheus.

   The hope of bringing to medicine the elegance that Copernicus had given astronomy dates from the time of Galileo. Descartes traced the coordinates for the implementation of the project. His description effectively turned the human body into clockworks and placed a new distance, not only between soul and body, but also between the patient's complaint and the physician's eye. Within this mechanized framework, pain turned into a red light and sickness into mechanical trouble. A taxonomy of diseases became possible. As minerals and plants could be classified, so diseases could be isolated and categorized by the doctor-taxonomist. The logical framework for a new purpose in medicine had been laid. Instead of suffering man, sickness was placed in the center of the medical system and could be subjected to (a) operational verification by measurement, (b) clinical study and experiment, and (c) evaluation according to engineering norms.

   Antiquity knew no yardstick for disease.17 Galileo's contemporaries were the first to try to apply measurement to the sick, but with little success. Since Galen had taught that urine was secreted directly from the vena cava and that its composition was a direct indication of the nature of the blood, doctors had tasted and smelled urine and assayed it by the light of sun and moon. After the sixteenth century, alchemists had learned to measure specific gravity with considerable precision, and they subjected the urine of the sick to their methods. Dozens of distinct and differing meanings were ascribed to changes in the specific gravity of urine. With this first measurement, doctors began to read diagnostic and curative meaning into any new measurement they learned to perform.18

   The use of physical measurements prepared for a belief in the real existence of diseases and their ontological autonomy from the perception of doctor and patient. The use of statistics underpinned this belief. It "showed" that diseases were present in the environment and could invade and infect people. The first clinical tests using statistics, which were performed in the United States in 1721 and published in London in 1722, provided hard data indicating that smallpox was threatening Massachusetts and that people who had been inoculated were protected against its attacks. They were conducted by Dr. Cotton Mather, who is better known for his inquisitorial fury at the time of the Salem witch trials than for his spirited defense of smallpox prevention.19

   During the seventeenth and eighteenth centuries, doctors who applied measurements to sick people were liable to be considered quacks by their colleagues. During the French Revolution, English doctors still looked askance at clinical thermometry. Together with the routine taking of the pulse, it became accepted clinical practice only around 1845, nearly thirty years after the stethoscope was first used by Laënnec.

   As the doctor's interest shifted from the sick to sickness, the hospital became a museum of disease. The wards were full of indigent people who offered their bodies as exhibits to any physician willing to treat them.20 The realization that the hospital was the logical place to study and compare "cases" developed towards the end of the eighteenth century. Doctors visited hospitals where all kinds of sick people were mingled, and trained themselves to pick out several "cases" of the same disease. They developed "bedside vision," or a clinical eye. During the first decades of the nineteenth century, the medical attitude towards hospitals went through a further development. Until then, new doctors had been trained mostly by lectures, demonstrations, and disputations. Now the "bedside" became the clinic, the place where future doctors were trained to see and recognize diseases.21 The clinical approach to sickness gave birth to a new language which spoke about diseases at the bedside, and to a hospital reorganized and classified by disease for the exhibition of ailments to students.22

   The hospital, which at the very beginning of the nineteenth century had become a place for diagnosis, was now turned into a place for teaching. Soon it would become a laboratory for experimenting with treatments, and towards the turn of the century a place concerned with therapy. Today the pesthouse has been transformed into a compartmentalized repair shop. All this happened in stages. During the nineteenth century, the clinic became the place where disease carriers were assembled, diseases were identified, and a census of diseases was kept. Medical perception of reality became hospital-based much earlier than medical practice. The specialized hospital demanded by the French Revolutionaries for the sake of the patient became a reality because doctors needed to classify sickness. During the entire nineteenth century, pathology remained overwhelmingly the classification of anatomical anomalies. Only towards the end of the century did the pupils of Claude Bernard also begin to label and catalogue the pathology of functions.23 Like sickness, health acquired a clinical status, becoming the absence of clinical symptoms, and clinical standards of normality became associated with well-being.24

   Disease could never have been associated with abnormality if the value of universal standards had not come to be recognized in one field after another over a period of two hundred years. In 1635, at the behest of Cardinal Richelieu, the king of France formed an academy of the forty supposedly most distinguished men of French letters for the purpose of protecting and perfecting the French language. In fact, they imposed the language of the rising bourgeoisie which was also gaining control over the expanding tools of production. The language of the new class of capitalist producers became normative for all classes. State authority had expanded beyond statute law to regulate means of expression. Citizens learned to recognize the normative power of an elite in areas left untouched by the canons of the Church and the civil and penal codes of the state. Offenses against the codified laws of French grammar now carried their own sanctions; they put the speaker in his place—that is, deprived him of the privileges of class and profession. Bad French was that which fell below academic standards, as bad health would soon be that which was not up to the clinical norm.

   In Latin norma means "square," the carpenter's square. Until the 1830s the English word "normal" meant standing at a right angle to the ground. During the 1840s it came to designate conformity to a common type. In the 1880s, in America, it came to mean the usual state or condition not only of things but also of people. In France, the word was transposed from geometry to society—école normale designated a school at which teachers for the Empire were trained—and was first given a medical connotation around 1840 by Auguste Comte. He expressed his hope that once the laws relative to the normal state of the organism were known, it would be possible to engage in the study of comparative pathology.25

   During the last decade of the nineteenth century, the norms and standards of the hospital became fundamental criteria for diagnosis and therapy. For this to happen, it was not necessary that all abnormal features be considered pathological; it was sufficient that disease as deviance from a clinical standard make medical intervention legitimate by providing an orientation for therapy.26

   The age of hospital medicine, which from rise to fall lasted no more than a century and a half, is coming to an end.27 Clinical measurement has been diffused throughout society. Society has become a clinic, and all citizens have become patients whose blood pressure is constantly being watched and regulated to fall "within" normal limits. The acute problems of manpower, money, access, and control that beset hospitals everywhere can be interpreted as symptoms of a new crisis in the concept of disease. This is a true crisis because it admits.of two opposing solutions, both of which make present hospitals obsolete. The first solution is a further sickening medicalization of health care, expanding still further the clinical control of the medical profession over the ambulatory population. The second is a critical, scientifically sound demedicalization of the concept of disease.

   Medical epistemology is much more important for the healthy solution of this crisis than either medical biology or medical technology. Such an epistemology will have to clarify the logical status and the social nature of diagnosis and therapy, primarily in physical—as opposed to mental—sickness. All disease is a socially created reality. Its meaning and the response it has evoked have a history.28 The study of this history will make us understand the degree to which we are prisoners of the medical ideology in which we were brought up.

   A number of authors have recently tried to debunk the status of mental deviance as a "disease."29 Paradoxically, they have rendered it more and not less difficult to raise the same kind of question about disease in general. Leifer, Goffman, Szasz, Laing, and others are all interested in the political genesis of mental illness and its use for political purposes.30 In order to make their point, they all contrast "unreal" mental with "real" physical disease: in their view the language of natural science, now applied to all conditions that are studied by physicians, really fits physical sickness only. Physical sickness is confined to the body, and it lies in an anatomical, physiological, and genetic context. The "real" existence of these conditions can be confirmed by measurement and experiment, without any reference to a value-system. None of this applies to mental sickness: its status as a "sickness" depends entirely on psychiatric judgment. The psychiatrist acts as the agent of a social, ethical, and political milieu. Measurements and experiments on these "mental" conditions can be conducted only within an ideological framework which derives its consistency from the general social prejudice of the psychiatrist. The prevalence of sickness is blamed on life in an alienated society, but while political reconstruction might eliminate much psychic sickness, it would merely provide better and more equitable technical treatment for those who are physically ill.

   This antipsychiatric stance, which legitimizes the non-political status of physical disease by denying to mental deviance the character of disease, is a minority position in the West, although it seems to be close to an official doctrine in modern China, where mental illness is perceived as a political problem. Maoist politicians are placed in charge of psychotic deviants. Bermann31 reports that the Chinese object to the revisionist Russian practice of depoliticizing the deviance of class enemies by locking them into hospitals and treating them as if they had a sickness analogous to an infection. They pretend that only the opposite approach can give results: the intensive political re-education of people who are now, perhaps unconsciously, class enemies. Their self-criticism will make them politically active and thus healthy. Here again, the insistence on the primarily nonclinical nature of mental deviance reinforces the belief that another kind of sickness is a material entity.32

   Advanced industrial societies have a high stake in maintaining the epistemological legitimacy of disease entities. As long as disease is something that takes possession of people, something they "catch" or "get," the victims of these natural processes can be exempted from responsibility for their condition. They can be pitied rather than blamed for sloppy, vile, or incompetent performance in suffering their subjective reality; they can be turned into manageable and profitable assets if they humbly accept their disease as the expression of "how things are"; and they can be discharged from any political responsibility for having collaborated in increasing the sickening stress of high-intensity industry. An advanced industrial society is sick-making because it disables people from coping with their environment and, when they break down, substitutes a "clinical," or therapeutic, prosthesis for the broken relationships. People would rebel against such an environment if medicine did not explain their biological disorientation as a defect in their health, rather than as a defect in the way of life which is imposed on them or which they impose on themselves.33 The assurance of personal political innocence that a diagnosis offers the patient serves as a hygienic mask that justifies further subjection to production and consumption.

   The medical diagnosis of substantive disease entities that supposedly take shape in the individual's body is a surreptitious and amoral way of blaming the victim. The physician, himself a member of the dominating class, judges that the individual does not fit into an environment that has been engineered and is administered by other professionals, instead of accusing his colleagues of creating environments into which the human organism cannot fit. Substantive disease can thus be interpreted as the materialization of a politically convenient myth, which takes on substance within the individual's body when this body is in rebellion against the demands that industrial society makes upon it.

   In every society the classification of disease—the nosology—mirrors social organization. The sickness that society produces is baptized by the doctor with names that bureaucrats cherish. "Learning disability," "hyperkinesis," or "minimal brain dysfunction" explains to parents why their children do not learn, serving as an alibi for school's intolerance or incompetence; high blood pressure serves as an alibi for mounting stress, degenerative disease for degenerating social organization. The more convincing the diagnosis, the more valuable the therapy appears to be, the easier it is to convince people that they need both, and the less likely they are to rebel against industrial growth. Unionized workers demand the most costly therapy possible, if for no other reason than for the perverse pleasure of getting back some of the money they have put into taxes and insurance, and deluding themselves that this will create more equality.

   Before sickness came to be perceived primarily as an organic or behavioral abnormality, he who got sick could still find in the eyes of the doctor a reflection of his own anguish and some recognition of the uniqueness of his suffering. Now, what he meets is the gaze of a biological accountant engaged in input/output calculations. His sickness is taken from him and turned into the raw material for an institutional enterprise. His condition is interpreted according to a set of abstract rules in a language he cannot understand. He is taught about alien entities that the doctor combats, but only just as much as the doctor considers necessary to gain the patient's cooperation. Language is taken over by the doctors: the sick person is deprived of meaningful words for his anguish, which is thus further increased by linguistic mystification.34

   Before scientific slang had come to dominate language about the body, the repertory of ordinary speech in this field was exceptionally rich.35 Peasant language preserved much of this treasure into our century.36 Proverbs and sayings kept instructions readily available.37 The way complaints to the doctor were formulated by Babylonians and Greeks has been compared with the expressions used by German blue-collar workers. As in antiquity the patient stutters, flounders, and speaks about what "grips him" or what he "has caught." But while the industrial worker refers to his ache as a drab "it" that hurts, his predecessors had many colorful and expressive names for the demons38 that bit or stung them. Finally, increasing dependence of socially acceptable speech on the special language of an elite profession makes disease into an instrument of class domination. The university-trained and the bureaucrat thus become their doctor's colleague in the treatment he dispenses, while the worker is put in his place as a subject who does not speak the language of his master.39

   As soon as medical effectiveness is assessed in ordinary language, it immediately appears that most effective diagnosis and treatment do not go beyond the understanding that any layman can develop. In fact, the overwhelming majority of diagnostic and therapeutic interventions that demonstrably do more good than harm have two characteristics: the material resources for them are extremely cheap, and they can be packaged and designed for self-use or application by family members. For example, the price of what is significantly health-furthering in Canadian medicine is so low that these same resources could be made available to the entire population of India for the amount of money now squandered there on modern medicine. The skills needed for the application of the most generally used diagnostic and therapeutic aids are so elementary that the careful following of instructions by people who are personally concerned would probably guarantee more effective and responsible use than medical practice ever could. Most of what remains could probably be handled better by "barefoot" nonprofessional amateurs with deep personal commitment than by professional physicians, psychiatrists, dentists, midwives, physiotherapists, or oculists.

   When the evidence about the simplicity of effective modern medicine is discussed, medicalized people usually object by saying that sick people are anxious and emotionally incompetent for rational self-medication, and that even doctors call in a colleague to treat their own sick child; and furthermore, that malevolent amateurs could quickly organize into monopoly custodians of scarce and precious medical knowledge. These objections are all valid if raised within a society in which consumer expectations shape attitudes to service, in which medical resources are carefully packaged for hospital use, and in which the mythology of medical efficiency prevails. They would hardly be valid in a world that aimed at the effective pursuit of personal goals that an austere use of technology had put within the range of almost everyone.

 

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