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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Serie: Key Concepts
- Sprache: Englisch
The second edition of Mildred Blaxter's successful and highly respected book offers a comprehensive and engaging introduction to the key debates surrounding the concept of health today. It discusses how health is defined, constructed, experienced and acted out in contemporary developed societies, drawing on a range of empirical data from the USA, Britain, France, and many other countries.
The new edition has been thoroughly revised and updated, with new material added on health and identity, the "new genetics", the sociology of the body, and the formation of health capital throughout the life course. The topic is the concept of health, rather than the more usual emphasis on illness and health-care systems. Special emphasis is given to the lay perspective to show how people themselves think about and experience health. Blaxter guides students through all the relevant conceptual models of the relationship of health to the structure of society, from inequality in health to the ideas of the risk society, the ‘socio-biological translation’ and the contribution of health to social capital. The book concludes with a comprehensively revised and thought-provoking discussion of the impact of new technology, the boundaries between life and death, modern commodification of health, technological transformations of the body and theories of evolutionary biology.
Health is an invaluable textbook for students of medicine and other health professions as well as those studying sociology, health sciences and health promotion.
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Veröffentlichungsjahr: 2018
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Table of Contents
Cover
Introduction
1 How is Health Defined?
Health as the absence of illness
Disease as deviance
Health as balance or homeostasis
Health as function
Health as state or status
The biomedical model
Contemporary biomedicine
The social model
Health, disease, illness and sickness
How is health measured?
Health capital
Conclusion
Further reading
2 How is Health Constructed?
Health as social construction
Constructions of history
Constructions of culture
Constructivism and feminism
Illness, labelling and stigma
Constructivism and mental illness
Constructivism and disability
The critique of relativism
Medicalization and the constructions of medical practice
Conclusion
Further reading
3 How is Health Embodied and Experienced?
Embodiment
Lay definitions of health
Social representations of health
Self-rated health
Concepts of the causes of health and illness
Health histories and subjective health capital
Illness narratives
The limitations of narratives
The search for meaning
Health as moral discourse and metaphor
Responsibility for health
Lay concepts and health behaviour
Further reading
4 How is Health Enacted?
The rise and fall of ‘illness behaviour’
Person to patient: help-seeking behaviour
The patient role – control and concordance
Enacted behavour
Behaving ‘healthily’
Structure/agency: health as cultural consumption
Structure/agency: health as self-governance
Further reading
5 How is Health Related to Social Systems?
A functional relationship
Responses to functionalism
Medicine and society
Health, economic development and social organization
The downside of economic development
The concept of inequality in health
The nature and extent of inequalities
The causes of inequality
The socio-biologic translation
Neo-materialist explanations
Social capital
Further reading
6 Contemporary Change in the Meaning of Health
Technology and postmodernity
Changing boundaries between ill and not-ill
The new genetics
Changing boundaries of life and death
Changing boundaries between self and not-self
Changing boundaries between therapy and enhancement
Information technologies and medical practice
Changing attitudes to health and medicine
New technologies and the risk society
Evolutionary medicine
Conclusion
Further reading
7 Conclusion
References
Index
End User License Agreement
List of Tables
5 How is Health Related to Social Systems?
Table 5.1 Life expectancy in Bethnal Green, London, 1842
List of Illustrations
2 How is Health Constructed?
Figure 2.1 Humoral theory
Guide
Cover
Table of Contents
Begin Reading
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e1
HEALTH
Second edition
Mildred Blaxter
Copyright © Mildred Blaxter 2010
The right of Mildred Blaxter to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First edition published in 2004
Second published in 2010 by Polity Press
Polity Press
65 Bridge Street
Cambridge CB2 1UR, UK
Polity Press
350 Main Street
Malden, MA 02148, USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-0-7456-4845-3
ISBN-13: 978-0-7456-4846-0(pb)
A catalogue record for this book is available from the British Library.
The publisher has used its best endeavours to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
Every effort has been made to trace all copyright holders, but if any have been inadvertently overlooked the publisher will be pleased to include any necessary credits in any subsequent reprint or edition.
For further information on Polity, visit our website: www.politybooks.com
Acknowledgement
This book was originally derived from a series of lectures presented to students in their first year of the Medical School in the University of East Anglia. Thanks are due to Professor Sam Leinster, Inaugural Dean of the Medical School, for his enterprising and generous belief that a sociological view of the concept of ‘health’ was one of the first things that prospective doctors should be introduced to.
Introduction
I don’t think I know when I am healthy, I only know if I am ill. (Office worker aged twenty-eight, UK, Blaxter 1990)
Health is both your inner and your outer state – the state of your soul – being more optimistic, not giving in to any kind of difficulties, trying to find some kind of compromise … and also, probably, being needed by society too, however old you are. (Nurse aged fifty-two, Moscow, Manning and Tikhonova 2009)
I think that if one day I wake up and I’m seventy, and I’ve lived like that, then I will say that’s good health … in short, it will have been life without incident. (Woman, France, Herzlich 1973)
Health is a state of mind, about knowing what to do and how to do it, how to cope. (Male clerical worker aged fifty-four, UK, Blaxter 2004)
My health is a reflection of my lifestyle – I need to be spiritually, mentally, emotionally and physically whole to be truly healthy. I believe complete wholeness is only attainable through reconciliation with God. (Herbalist, UK, Stainton Rogers 1991)
What is health? That’s a silly question! (Driver aged thirty-nine, UK, Blaxter 1990)
What is health? Many studies have asked ordinary people this question, and their replies, as these brief examples from research in different countries show, range from the thoughtful to the dismissive. Few people think about their health all of the time, but for most it is, at least intermittently, an important topic. How are you? The common greeting may not actually expect an answer in medical terms, but health is one of the most ubiquitous topics of conversation in everyday life. At the same time, health and medicine are major sections of the social organization of any society, and a great deal of resources and manpower go into systems for the promotion of health and the management of disease.
It may seem obvious that we must know what ‘health’ is. However, it is not only something on which individuals can have very different views, but also a concept which has inspired endless theorizing and dispute throughout the centuries.
This volume attempts to summarize where we are now, in the early twenty-first century, in thinking about health. The emphasis is on contemporary ideas and their development during the last century or so. A historical approach is the starting point, and consideration of the latest developments and speculation about how the concept of health is changing is a major focus. The emphasis is upon what is known as ‘Western scientific medicine’, because this is the system to which most developed societies subscribe and which tends to be adopted by most developing societies. This is not, though, to denigrate other, non-Western, systems of belief, or to ignore the way in which ‘alternative’ ideas are incorporated into modern ideas of health.
The central discipline here is medical sociology. But others make contributions – psychology, biological science, clinical medicine, social epidemiology, philosophy, anthropology, history of medicine, policy and politics. This, again, shows how deeply embedded ideas about health are, and how many perspectives may be brought to bear.
The volume is not presented as a textbook of the whole of medical sociology, or a review of all the facts and figures of what is usually called social medicine. Rather than a textbook, it is an introduction to ideas about health, which may provide students of any of these disciplines, and especially those in medicine, nursing, and other health professions, with provocative ways of thinking about its social aspects. It attempts to demonstrate the particular contribution of modern social science to medicine, and, while keeping references to research studies to a minimum, it introduces some of the best writing and all the most important scholars on the subject. Since concepts are not easily reduced to statistics, most of the material is qualitative rather than quantitative. The topic is, as far as possible, health rather than illness, and health rather than health-care systems.
This revised edition not only brings the text up to date, but introduces new material which relates especially to current developments in science and technology which are fundamentally altering our perceptions of the body and redefining health.
Besides its intellectual interest, the book has practical relevance for health systems and those who study or work in the health-care professions. As will become evident, ways of defining health have always influenced the practice of healers and the organization of care, and continue to play a part in determining the social policies of nations. The meaning of health is neither simple nor unchanging.
1How is Health Defined?
Health may be defined differently by doctors and their patients, and over time and place. One of the most pervasive definitions, though, is simply normality, with illness as a deviation from the normal. The definition of disease as abnormality or damage – physiological, biochemical or psychological – held sway in modern thought for most of the last century. It is represented in lay thought by the replies commonly given in surveys to an invitation to define health: health is not being ill, health is having no disease. It is represented in clinical medicine by the whole array of tests and standards, rapidly growing in sophistication, to measure ‘normal’ body size and weight, blood composition, lung capacity, functioning of the liver, and so on, through every organ and system of the body.
This definition raises many problems, however. What is normal – normal for what, and for whom? (Clinical standards usually assume for a particular age and gender, but no more.) ‘Normal’ can have many meanings: average, most representative, the most common value, central in a distribution, the habitual or the best. Are we talking about the average for a given population, or some ideal? The ‘perfect’ is not only impossible of attainment, but also not necessarily to be desired. As Hippocrates noted in the Aphorisms:
In athletics a perfect condition that is at its highest pitch is treacherous. Such conditions cannot stay the same or remain at rest, and, change for the better being impossible, the only possible change is for the worse.
On the other hand, normal defined as average may not mean perfectly healthy, and the average – consider the examples of body weight or cholesterol level – may not be at all what clinicians regard as the ‘norm’ or ideal to be aimed for. What is normal degeneration in old age: are all the old unhealthy? Not all deviations from the normal are to be deplored or ‘treated’: some can be positively beneficial, and others are irrelevant to health. Erde (1979: 36) noted:
If you are 80 or running a marathon, what is normal would differ from the ‘norm’ of someone age 20 or asleep. Furthermore, if you can run two marathons and no one else can, you may be abnormal and yet as healthy as can be. If your IQ is 100 it is normal. If it is 140, your mind’s functions are not in a normal state. We need to know what ‘normal’ means, before we can tell whether someone has it or is it.
In other words, normal can be descriptive or proscriptive, and if it is proscriptive it has to depend on the state of knowledge at the time, or accepted current theory. A softer version is the recognition that there is a great range of normal variability, and only that which falls outside it need be considered as ill health. The range has still to be defined, perhaps arbitrarily.
Health as the absence of illness
For a time in the mid-twentieth century there was promulgation of the idea of disease or ill health as those phenomena which deviate from the norm in such a way as to place the individual at biological disadvantage. The healthy are those who are not biologically disadvantaged. To some extent this avoids the problems of the definition of normality, since those deviations which have no consequences are irrelevant. But it created new problems in the definition of disadvantage, which was usually described very specifically as shortened life and reduced fertility.
Commentators in the field of mental health used this to argue opposed positions: though no physiological abnormalities had so far been found to account for a condition such as schizophrenia, nevertheless it was a disease, using the biological disadvantage criteria. On the other hand, it was pointed out that many forms of mental ill health did not reduce life expectancy or fertility: was it impossible to call them diseases? In general, the focus on length of life and fertility seemed too Darwinian (disease is anything which interferes with the preservation of the species) and too restrictive.
A more subjective view can be taken, of course, resting the definition of health not on measurable, clinically defined abnormality, but on people’s own perception of the experience of symptoms or feelings of illness. The problem is that the norm becomes even more difficult to define. It is commonly demonstrated in studies of populations that to experience no symptoms of ill health at all – never to have pain, mild dysfunction, infection or injury – is in fact highly abnormal: most of us, most of the time, can identify something which we might call a symptom of an illness. Only a small proportion of this is taken for professional attention and diagnosis as disease, and much of it is self-limiting.
Any definition of health as the absence of self-perceived illness has to deal with the fact that this perception varies widely among individuals and depends on situations. Questions have again to be raised about normal illness – normal for this particular person, normal for this sort of individual, normal in these circumstances? – with even less certainty about what the average is, or what would be considered as the ideal.
Disease as deviance
The idea of health as the absence of disease or illness, and disease as deviation from the norm, elides easily into ill health seen as ‘deviance’ from social or moral norms. The objective observation of a lack of ‘normality’ meets a very ancient and universal tendency to see the sick person as in some way morally tainted or bewitched. Possibly, they are responsible for their own condition, and at best they are being offered the opportunity to gain merit or show their strength of character in enduring suffering. Ill health usually has negative connotations, and is spoken of as ‘bad luck’ for the individual. Ill health also harms the functioning or the prosperity of society: the sick are not productive, they may require resources, and they must be controlled and monitored. Thus the American sociologist Talcott Parsons’s treatment of sickness as a role designed to allow ‘deviants’ to find conditional and provisional legitimacy was influential in early medical sociology.
Health as balance or homeostasis
A link between the concepts of health and normality lies in the ancient idea of homeostasis – the idea that the normal state of the body is order, and its systems are designed to be self-righting. This old idea was given new life when it was realized that not only a pathogen, but also a host – the body which was being invaded or harmed – was actively involved in the development of ill health. When a system was being attacked by a specific agent, or was disordered by biological error or stresses and accidents in the environment, regulatory mechanisms came into play. Restoring the normal involves not only equilibrium of the human organism – mind and body – with its environment, but also internal equilibrium within the body’s functions and organs. Ill health arises when the balance is disturbed. In modern times this approach gained attraction from its association with the growth of ecology as a natural science.
As commentators such as Mishler (1981) have pointed out, this has elements of older, perhaps less scientific concepts. It echoes the classical Platonic model of health as harmony among the body’s processes and systems, with disease as a state of discord, and the Galenian concept of disease as a disturbance of function. Before the rise of modern medicine, not only the cultures of the West but all the great cultures of the world, such as those of China or India, held that health is to be defined as the right balance between supernatural beings, the environment, and processes within the body. Disease as imbalance had to be corrected by the remedying of deficiency (by, for instance, diet) or the removal of excess (by, for instance, purging or bleeding).
A theory of health has to accommodate the fact that all living things have some ability to respond to changing environments. The commonly accepted stance is that the environment does not wholly determine the properties of the organism which is, at least partly, self-organized and capable of change. Modern medicine shows that in certain physiological aspects the body is indeed a homeostatic machine: for instance, the immune system responds when infection enters the system, and loss of blood by injury is responded to by vasoconstriction to keep blood pressure steady. The capacity to sustain equilibrium, or more generally the ability of the body to heal itself, can be regarded as a measure of its healthiness. These ideas, ancient in principle, are elaborated by the findings of modern science. As a total model of health, however, homeostasis has limitations. This is undoubtedly part of healthiness, but some healthy functions – reproduction, for instance – upset equilibrium rather than maintain it, and not all systems are even theoretically self-righting. It can be accepted that some aspects of equilibrium are crucial to life, without confusing the idea of homeostasis with the broader ideal of the normal.
Health as function
This does, however, move away a little from the essentially negative definitions. Another, and even more positive, way is in terms of function. Health is being able to do things. This can be a very basic definition: as a woman of 70 said, when asked what it means to be healthy,
Health is being able to walk around better and doing some work in the house when my knees let me. (Blaxter 1990)
Functional health can be thought of in terms of having a fit body, not being restricted in any way, being able to do the things one wants or needs to do, all the natural functions of ordinary life being performed freely and without pain. This, again, connects to modern ecological ideas by being defined as being well adapted to the environment, engaging in effective interaction with the physical and social world. Ill health is incapacity, whether caused by disease, accident, the degeneration of old age, or less than perfectly functional development at the start of life. Disease is failure in adaptation, and is dysfunctional both to individuals themselves and to the societies of which they are a part.
Another popular functional definition of health is as ‘the ability to reach desired goals’ (Porn 1993), essentially a concept in terms of adaptive functioning. There are some obvious problems with this definition of health. As Levy (2007) noted, a natural baseline is difficult to define, for people – even in the same place and time – can vary biologically because of a myriad of influences, and normal expectations for one individual can be highly abnormal for another. It depends on what one wants or needs to do: perfect function in a young athlete and in an elderly, sedentary person represents different physical capacities. And functional incapacity is not necessarily dependent on health – as Erde (1979: 35) commented: ‘Being stuck in a door would automatically make someone unhealthy if this definition were held.’
Health as function easily progesses into health as fitness, with the question ‘fitness for what?’ unanswered. A very restricted answer is simply ‘the activities of daily living’ – mobility, caring for oneself, working. This immediately tends to define those with physical, sensory or mental disabilities as unfit and raises questions about whether impairments – inability to see or hear, for instance – are to be called ill health. Those who speak for people with disabilities would contest this fiercely, arguing that any impairment is more or less disabling depending on the environment: there are disabling environments, not disabled people.
Health as state or status
Confusion commonly arises because of another problem: is health to be defined as a temporary state (am I ill today?) or a longer-term status (am I basically a healthy or unhealthy person?)? That people themselves clearly make this distinction is attested to by replies to polite questions such as ‘How are you?’, which are often ‘Well, I have a cold, but in general I’m very healthy’, or answers in health surveys to questions such as ‘Are you in good/fair/poor health?’, which can take difficult-to-categorize forms such as ‘I’ve got diabetes, but my health is excellent.’
The distinction is not entirely the one which medicine conventionally adopts between the acute and the chronic. All ill health cannot be forced into one of these two categories: people may be ‘chronic’ sufferers from acute conditions, long-term chronic disease results in varying degrees of acute illness at any particular time. ‘State’ represents the present health state of the individual, distinct from (though of course commonly associated with) their health status or the general characteristic of being healthy or unhealthy. Health ‘status’ is a longer-term attribute, changing rapidly only in the event of the sudden and unexpected onset of serious illness or permanently damaging trauma. Health state, on the other hand, is an erratic condition, relevant to health status only if it derives from it or if (because of its typicality or frequency) it reflects back to be incorporated into health status.
Health state and health status have some association with the health economist’s concept of health as ‘stock’ or capital and health as ‘flow’. Health capital (see p. 25) can be conceived of as the cumulation of health states – illnesses, accidents, malfunctions, increases or decreases in fitness – which the individual or the group experiences.
The biomedical model
There are thus many ways in which health might be defined, for the most part resting on ideas of the ‘normal’ and of seeing health as opposed to disease or illness. In practice, the definition of health has always been formally the territory of those who define its opposite: healers, or practitioners of medicine as a science or a body of practical knowledge. Since medicine is one of society’s major systems, it is obvious that it is these definitions which will be institutionalized and embodied in law and administration, though the extent to which ‘lay’ models add to or diverge from this body of ideas will be considered later.
The basic paradigm of medicine since the development of the germ theory in the nineteenth century has been what is called the biomedical model. In its stereotypical form, this has been based on, and almost wholly dominated by, the methods and principles of the biological sciences. Such a model would naturally be based on the ‘disease’ which it is the function of medicine to treat, and thus on ill health rather than health.
Historians of medicine note how two ways of thinking about health have appeared and disappeared throughout the development of Western medical practice. Disease can be seen as independent of the patient:
The doctor will be different in the Western tradition, because he will be looking through the ill person to the disease that caused the illness. The trained doctor will have a form of contract, not with individuals, but with the diseases that use these individuals as media. (Neve 1995: 479)
Alternatively, as in Hippocratic medicine, the individual, with all his or her particular circumstances, diet, dreams and habits, can be seen as of first importance.
The first way came to predominate after the Enlightenment, when the work of scientists such as Pasteur and Koch in the nineteenth century demonstrated that specific diseases could be introduced into the body by specific microorganisms. The earlier ‘anatomists’ and pathologists had begun to trace out the structures of the body and the way it functioned, introducing mechanistic models of the processes involved. The new bacteriological science now, however, transformed notions of the practice of medicine. It meant that doctors need no longer be limited by their observation of mechanical processes or rely on accounts of subjective symptoms. Science, and the body’s own immune system, could conquer ancient scourges such as cholera, diphtheria or tuberculosis by vaccination and inoculation.
The fundamental principles of the biomedical model began to include the following;
(1) The first principle is what is called the doctrine of specific etiology, that is, the idea that all disease is caused by theoretically identifiable agents such as germs, bacteria or parasites. The influence of germ theory was powerful, spreading rapidly from infectious diseases to others produced by known, specific, causes – metabolic processes, disturbances of growth or function. An obvious corollary of such a model is that explanation will be thought to be ‘better’ – more complete – the more that description has moved from an initial taxonomy, or categorization, of individual symptoms through the identification of a ‘syndrome’ or cluster of symptoms to a final diagnosis of a disease with a single cause.
Criticisms of this principle focused principally on the suggestion that it oversimplified biological processes now known to be very complex. For many diseases there are multiple and interacting causes. Moreover, such a principle looks only to the agent of disease, and ignores the host, and the possibilities of biological adaptation. The scientist and medical historian Rene Dubos, in his influential books Mirage of Health and Man Adapting nearly half a century ago, asked, for instance, why does infection not always produce disease? Why is disease comparatively rare though infectious agents are present everywhere? The principle is much more easily applicable to acute conditions than to chronic ill health and is difficult to apply to mental disorders.
(2) A second principle of the biomedical model is called the assumption of generic disease – the idea that each disease has its own distinguishing features that are universal, at least within the human species. These will be the same in different cultures and at different times, unless the disease-producing agent itself changes. As Sydenham declared in the seventeenth century: ‘All diseases should be reduced to certain definite species with the same care which we see exhibited by botanists in their description of plants.’
Criticisms of this focus on the rather obvious point that diseases are differently defined in different cultures and that medical definitions of disease have clearly changed over time. Each new advance in knowledge of physiology and each new wave of technology has added new definitions of ill health to the accepted canon. Despite the doctrine of specific etiology, many conditions which are still only symptoms or syndromes are recognized within medicine as ‘diseases’. More generally, it can easily be shown (chapter 2) that what is viewed as illness in any particular society and at any historical time depends on cultural norms and social values.
It has been argued that in practice a condition is defined by medicine as a disease if and when it is felt that clinical means are appropriate for treating it: ill health is simply what doctors treat. The answer that doctors give to the question ‘Is this a disease?’ is really an answer to the question ‘Can I, or do I want to, treat this person?’ (Linder 1965). This is not always true, of course, for doctors treat many people they do not see as ‘diseased’. But it can be demonstrated that frequently the act of diagnosis is primarily the process of deciding what the appropriate treatment is (Blaxter 1978).
Thus ‘new’ diagnoses – new diseases – such as alcoholism, post-traumatic stress disorder, chronic fatigue syndrome, are born through an interaction of new knowledge about both their possible causes and how they might possibly be helped. As a definition of disease, ‘what doctors treat’ has obvious problems, however. It implies that no one can be ill until recognized as such, and leaves the concept at the mercy of idiosyncratic individual medical decisions.
(3) A third principle of scientific biomedicine is that it accepts the model of all ill health as deviation from the normal, especially the normal range of measurable biological variables. In the mid-nineteenth century Virchow proclaimed that disease was simply altered physiology: ‘Nothing but life under altered conditions.’ There is an association with the definition of health as equilibrium and disease as a disturbance of the body’s functions, with the purpose of medical technology the restoration to equilibrium. The immune, or endocrine, or neuropsychological, systems attempt to restore the ‘normal’, and the purpose of medicine is to instigate or assist this process. But medical science now realizes that the human organism has no set pattern for structure and function, and it is often unclear where normal variation ends and abnormality begins. Kendall (1975: 305) asked: ‘Is hypertension a disease, and if so what is the level beyond which the blood pressure is abnormal?’, and suggested that it was in fact this example of hypertension which finally discredited the nineteenth-century assumption that there was always an observable, measurable distinction between illness and normal health.
(4) The fourth postulate of medical science was that it was held to be based on the principles of scientific neutrality. Medicine adopts not only the rational method of science but also its values – objectivity and neutrality on the part of the observer, and the view of the human organism as simply the product of biological (and perhaps psychological) processes over which the individuals themselves have little control.
The reply to this is that the practice of medicine, whatever its theory, is always deeply embedded in the larger society. It cannot be neutral, for there are wider social, political and cultural forces dictating how it does its work and how the unhealthy are dealt with. The diagnoses of female hysteria in the nineteenth century, or Gulf War Syndrome in the twenty-first, cannot be thought to be culturally or politically neutral.
Contemporary biomedicine
Residues of all four of these postulates can be found in contemporary medical practice. But it would be a caricature to present them as defining modern medicine: it is a long time since the medical model espoused crude models of cause and effect. The assumption that every disease had a distinct cause, which was both necessary and sufficient, had to be given up as it became apparent that a great many interacting factors, whether inside or outside the individual body, contributed to any ill health. To regard one as the cause became increasingly arbitrary. During the first half of the twentieth century, for instance, it was noted that the tubercular baccillus was a necessary cause of tuberculosis – that is, the disease would not be present if the agent was absent – but it was not a sufficient cause. The baccillus was widespread in many populations, but only a minority of people actually developed the disease.
The model of the causation of ill health changed from the simple, direct effect of a bacillus or virus, to include the immune system as intermediary, and eventually to include a wide range of influences on the agent and on the host’s response to it.
Biomedicine now admits multiple and interactive causes, and that the whole may be more than simply the sum of the parts. The rise of psychology was also relevant in altering the purely mechanistic model of illness. Increasingly evidence was gathered – to add sufficient scientific proof to what had probably always been personally felt and professionally recognized – to show that psychological factors affect many illness conditions, and many if not most conditions have some psychosomatic elements: that is, they are genuine organic conditions but have at least some psychological factor in their cause.
This is, however, an elaboration of the medical model rather than a fundamental revision. Social and psychological causes of ill health – stress, unhappiness, life events – are admitted as agents of disease, or contributing factors, but they are not themselves defined as ill health.
In the light of the most influential critiques of the medical model and the movement, strong in the mid-twentieth century, to include the psychological within it, it would obviously be foolish to present the pure ‘biomedical model’ as still separate and in opposition to the ‘social model’ which will be considered next. Modern medicine has moved on, to incorporate elaborate ideas about the various and interrelated causes of ill health. However, though ‘Koch’s postulates’ of specific etiology and so on may not nowadays be taught in medical schools, their echoes still sound in medical discourse and their influence can still be seen in medical practice. Studies of the way in which doctors make diagnoses demonstrate this, while at the same time lipservice is paid to the importance of the ‘social’. Moreover, even when social and psychological influences are admitted, this is still a very negatively oriented approach to considering illness rather than health.
The social model
Around the middle of the twentieth century there was increasing dissatisfaction with the dominant model of health offered by biomedicine. The preoccupation with disease and illness made it less able to deal with any positive concept of health. The ideology which viewed the individual in mechanistic ways justified ever-increasing use of medical technologies, discouraging the exercise of other therapies and diminishing the importance (and the resources) allocated to positive health, or preventive medicine.
Notably, the American philosopher Ivan Illich (1974: 918) claimed that medical professional practice was itself a threat to health, identifying the syndrome he called ‘medical nemesis’:
