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Evolution of Sickness and Healing

University of California Press

Members of all societies encounter disease and injury and develop social practices to cope with their effects. Social practices can also lead to disease and injury. The existence of medical problems and institutions to handle all of this can be regarded as a cultural universal (Brown 1991). Social scientists have described much variety in the way societies cope with disease and injury. There is a need for theoretical consolidation of this field. One of the principal tasks is to develop a frame of reference and a set of concepts in terms of which this variability could be organized and explained.

The basic material of medicine that requires explanation is that involving sickness and healing as these are configured and played out in different types of societies. As social and cultural phenomena, sickness and healing need to be studied from a holistic standpoint: The dialectic is between the physical environment, disease/injury as biological phenomena, and sickness and healing that are constructed as a function of the preceding and of social organization itself. This, in essence, is the enterprise of this book, with the added intention of interpreting changing aspects of medicine in terms of biological and social evolution. The purpose of this chapter is to discuss some fundamental issues, both methodological and conceptual, that pose problems for one attempting to develop a comparative approach to sickness and healing.

A clear hindrance to the development of a unified, comprehensive, and theoretical approach to the institution of medicine has been the sheer difficulty

of incorporating in one frame of reference the different kinds of disease problems that exist and the variety in the way they can be expressed in one society, regardless of its level of complexity or modernity. This would include the range of injuries, neuromuscular dislocations, anatomical fractures and contusions, and like phenomena that can befall people as a result of physical happenings. It would also include the range of infectious problems, systemic and local, that populations are vulnerable to, infections that vary as a function of a society's geography, characteristics of the physical habitat, dietary intake, level of social stress, and level of social organization and complexity. Besides infectious problems, there exist a plethora of disease processes involving metabolism, disorders of physiological function (e.g., gastrointestinal, respiratory, cardiovascular, genitourinary), and diseases of unknown etiology (e.g., cancer, multiple sclerosis, varieties of arthritis). Finally, one would have to include so-called emotional and functional medical problems that constitute a very large percentage of what physicians actually observe and are forced to treat in some way. This would include a large amalgam of somatically, psychologically, and behaviorally expressed ailments that in biomedicine today are not clearly classified from a causal standpoint. The amalgam would include a large segment of somatic conditions traceable to stress as well as most of the more clearly profiled psychiatric disorders, all of which prominently include somatic problems and very often still make their initial medical appearance in primary care settings because they manifest somatically and are so interpreted (e.g., depression, anxiety, dementia, psychoses of different types).

That these medical problems are dealt with by a large number of different types of biomedical specialists (clinical practitioners and public health oriented) and are thought of as different precisely because of the way they are defined, classified, and dealt with by the respective medical disciplines creates further difficulty for one intending to formulate a satisfying (i.e., comprehensive yet parsimonious) theoretical approach to medicine. At the very least, this heterogeneity of problems, although obviously neatly packaged biomedically, refers to highly diverse human phenomena of suffering that disable and incapacitate in different ways, that persist for different degrees of time when manifest, and that can be ameliorated from a symptomatic standpoint (short of acute surgical or pharmacologic intervention) to differing degrees and for different amounts of time. All of these problems, in short, create the formidable profile of morbidity and mortality that constitutes a society's medical burden and that one intending a theoretical amount of the medical must attend to.

A way of coping with the problem of the complex and variegated nature of the material content of the medical is to divide the theoretical labor and handle the material in different modes. From the standpoint of researchers in epidemiology and clinical medicine, the task is to identify the profile of medical problems that these scientists as well as physical anthropologists, archaeologists,

and paleopathologists equate with societies classified as to level of social organization and complexity as well as ecology or physical habitat.

Societies, of course, are not neatly isolated "things" one can study as though their approaches to the medical were unique. Nor is the structure of any society exactly like that of another, given the range of factors that can affect them. Rather, and despite apparent similarities and insularities, societies differ in any number of ways and are always in contact with each other. Medical phenomena in any one society and at one point in time reflect spread of diseases and cultural borrowings from other societies (McNeill 1976, 1992). A comparative, unified view of how societies construct and play out sickness and healing requires that one adopt an abstract frame of reference and a set of typologies that facilitate analysis.

One can assume that a particular "social type," namely, a society characterized by a distinctive set of structural properties, has associated with it a more or less distinctive profile of medical problems that constitutes the material content of the medical. In any theoretical account of medicine, this material would have to be in some way referenced since it constitutes the base out of which a people think about, approach, and cope with the medical. On the other hand, from the standpoint of a comparative social and cultural approach to the medical, the task is to rely on root concepts in terms of which one is afforded a way of fruitfully organizing and conceptualizing this material content of the medical of any particular society in social and cultural terms. In short, abstraction, reduction, and theoretical economy and precision are necessary here as well.

Illness, an individual's perception of a medical problem, sickness, the social construction of a condition of illness, disease, or pathology, what exists from a physical/organic standpoint, and healing, the range of medicines, procedures, and rituals by means of which a people try to prevent, undo, or minimize morbidity, are basic concepts that have been used in the past in medical anthropology and will be adopted here (Fabrega 1974; Frankenberg, 1980, 1986; Good 1977; Kleinman...