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Tranquillity & Well Being
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Grace and Sara MacBride-Stewart. By: Stella Howden. This material, which includes reviews of social organization of the societies, epidemiological and ecological factors, and aspects of sickness and healing in each of the selected social types, is discussed in chapters 3 and 4.
Individuals living in family-level societies during the line of evolution to Homo sapiens are judged to have evolved a distinctive framework for medicine. This framework, consisting of orientations and behaviors related to sickness and healing, is judged to have been transformed as societies evolved and became more complex. The two chapters offer a summary account of how sickness and healing have been configured and played out in different types of societies. Some of these ideas on the evolution of sickness and healing are elaborated by discussing the role that active substances and drugs might have played in different historical periods chapter 5.
A more indepth account of sickness and healing in different types of societies is illustrated by giving attention to somatopsychic disturbances chapter 6. These are important medical disorders in biomedicine today, and there are good reasons for believing not only that they are universal but also that they constitute a good barometer with which to record the interplay of culture, society, and bi-.
This line of analysis is pursued in chapter 6. In chapter 7 I introduce the concept of a "medical meme" to refer to the basic unit of information pertaining to how sickness and healing are configured and played out. This concept serves as a bridge for linking the biological and cultural evolution of medicine and is used here and in later chapters as a way of giving substance and focus to the evolution of medicine.
In this chapter I also consolidate earlier descriptive material by summarizing general parameters pertaining to sickness and healing in each of the different types of societies analyzed earlier. In chapter 8 concepts and principles are further elaborated in my attempt to conceptualize sickness and healing as well as the institution of medicine in an evolutionary frame of reference. The inner workings of the adaptation at the base of medicine are analyzed more fully. In particular, the role of medical genes in producing the machinery of the adaptation for medicine is discussed together with the relationship they are thought to have to medical memes, which produce the expressive, meaning-centered aspects of the adaptation.
In addition, what I regard as the ontogeny of this adaptation is reviewed together with its implications. The adaptation is judged as providing the conditions that together with social environmental inputs pertaining to experiences with disease and injury during critical periods of development lead to the unfolding of sickness and healing orientations and behaviors. Finally, the tie between the material of the adaptation and the material that sociologists and economists have in mind when they discuss institutions and their social evolution is reviewed. All of this provides a way of integrating the study of the biological and cultural evolution of medicine.
In chapter 9 I step back and examine aspects of the evolution of medicine from a broader point of view. I present a diagram for illustrating the various types of phenomena implicated in this evolution. The institution of medicine is conceptualized as incorporating differing materials and systems, beginning with genes and ending with social organizations, corporations, and material products.
The institution of medicine is connected to other institutional sectors of any society, and these are included in a macrosociological schema of society. The changes in the differing components of medicine and in the society during evolution are summarized. In chapter 10 I discuss some of the implications of studying medicine from an evolutionary standpoint, giving attention to topics in social medicine, clinical medicine, and social theory. In chapter 11 I review my thinking and discuss ways in which an evolutionary perspective on medicine can be used to examine contemporary problems in biomedical practice.
In the appendix I summarize my argument by providing an outline of the concepts and a description of the characteristics of the stages of the evolution of medicine. A general view of my intellectual orientation is appropriate here. A common interpretation of evolution is betterment and progress. There unquestionably have resulted enormous gains in the treatment of many types of disease during the rise and development of biomedicine.
And prior to this, one could reasonably claim that practitioners of many of the ancient "great traditions" of medicine, such as those of China, India, and the ancient Mediterranean societies, produced more enlightened, successful understandings of sickness and healing compared to other, smaller and less evolved traditions. Even the latter approaches cannot be said to be without their benefits as research studies centered on the value of native healing rituals and local, indigenous medicinal preparations continue to elucidate.
In conflict with a view of the unquestioned beneficial effects of social evolution on health and medicine is the body of work of physical anthropologists on the comparative nutrition and health of prehistoric and early historic populations. This line of investigation tends to support the relatively high nutritional status and physical health of foragers and hunter-gatherers. Moreover, and although this is contested, the consensus of opinion seems to point to possible relative declines in nutrition and health of populations in association with the major social and economic revolutions involving subsistence patterns and population density and size.
Based on this line of thinking, then, it would be difficult to conclude that growth and "evolution" of a society's medical tradition and approach to disease, which one can equate roughly with the major social and economic revolutions of human groups across history and prehistory, always resulted in improvement or progress. It needs to be emphasized, then, that the "success" of a tradition of medicine is difficult to establish and is much contested.
Many of the gains in morbidity and mortality associated with the modern era, as an example, have been explained as resulting from improvements in sanitation, hygiene, and diet rather than from medical practice per se. And from a theoretical standpoint, an argument can be made to the effect that the value of a tradition of medical care should be measured in terms, not exclusively of epidemiological indices per se, but of those pertaining to how sickness problems as identified by that tradition are handled.
With respect to the latter point, several factors linked to sickness and healing, not just success in eliminating or controlling the underlying disease or injury, should be taken into account, for example, success in relieving pain and suffering, success in facilitating the social losses occasioned by disease and injury, success in promoting sociopsychologic reconditioning, and success in providing for comfortable ways of dying in the event that healing is unsuccessful.
Finally, it should not be forgotten that otherwise exemplary healing traditions can cause disease and injury so-called iatrogenic medical problems and these "losses" of an otherwise "scientific" medical tradition would have to be balanced with its gains in any strict accounting of its overall "success. For these and related reasons, then, the conceptualization of an evolution of medicine proposed in this book should not be taken to imply progressive improvements in the handling of disease and injury. In fact I believe that there are. An advantage of formulating medicine from an evolutionary standpoint anchored in human biology is that it serves to more clearly profile the good and the bad of contemporary medicine.
My frame of reference and proposal is also not in any strong way a functional one. I certainly do not believe that there is a purpose, function, or design and direction that explains why and how evolution has occurred in medicine. These caveats about medical evolution as progressive and having taken place for functional reasons are consistent with contemporary thinking on social evolution generally. Rather, the conceptualization I propose aims to depict what aspects of sickness and healing differ in the various types of societies that are held to form, in a rough way, a continuum of size and complexity and to have constituted, in an abstract way, probable phases in the posited evolution of society, however controversial and contested this area of study might be.
I aim to show, in other words, how the construction of sickness changes in relation to changing levels and degrees of social organization; and similarly, how approaches to healing change as a result of these types of social changes. In addition to describing sickness and healing in different types of societies, I attempt to explain how transformations in the configuration of sickness and healing might be presumed to have taken place.
My aims, in short, are to offer a descriptive interpretation of the evolution of medicine, to provide a conceptual frame of reference for visualizing this evolution, and to propose a methodology for studying it. It is important to emphasize that I identify my effort as an introduction. I see it as pointing the way toward a more theoretically integrated conceptualization of medicine. My approach is to use basic knowledge of disease, injury, and the social aspects of medical care to provide a better way of looking at how medicine as a social institution arose, unfolded, and transformed itself during the course of human evolution and history.
I believe that this way of conceptualizing medicine provides a useful frame of reference from which to examine practical matters pertaining to medical practice and care and theoretical ones pertaining to the social sciences. It is difficult to give credit to all persons who have provided help and support in this undertaking. I am especially indebted to Tom Detre for having enabled me, early in my career, to appreciate through his clinical brilliance the beauty and scientific integrity of academic psychiatry. He also provided me with support, continued intellectual interest, and goodwill during my academic work at the University of Pittsburgh.
Since my medical school days, Howard P. Rome was a source of inspiration, encouragement, and renewal, and I am very pleased to acknowledge this here. Gene Brody is another person whose positive influence has been constant and sustained over the years and whose implicit encouragement I have valued greatly.
About this book
In his unique "Latin" way Juan Mezzich has always been encouraging of my work, and this has been very sustaining. George C. Williams reviewed one of the chapters, and I found his remarks encouraging and illuminating. Tom Fararo and John Marx have read portions of certain chapters, and their warm endorsement of my thinking was instrumental in furthering my resolve in this project. Steve Gaulin's help in guiding me to relevant literature, his interest in my ideas, and his mental toughness in response to my queries have proven very helpful.
My dealings with the Press were very positive: I am grateful to Stanley Holwitz for his continued encouragement and to Michelle Nordon for her patience and goodwill in shepherding the manuscript. Finally, I wish to acknowledge the patience, acceptance, and sheer hard work of my wife, Joan Rome Sporkin, whose dedication to shared pursuits of family goals provided me with the time and reclusion for my writing. 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 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. 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. 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. 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. 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.
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,. 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 , 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. In later chapters, these basic concepts are supplemented by others that will serve to cast medicine in a more suitable theoretical frame of reference as the occasion demands. Good ethnographies of sickness and healing are basic requirements for theoretical discussions of medicine that are truly comparative.
The field of medical anthropology contains many in-depth studies of sickness and healing. Several studies can be cited as classic examples Glick ; Harwood ; Lewis ; Nash ; Ngubane ; Turner Recently, there has. Characteristically, this interest has expressed itself in textual analyses of beliefs about sickness and healing practices, looked at as complex and elaborate systems of symbols Dols a; Farquhar ; Sivin ; Unschuld , a, b; Zimmermann Emphasis on the richness of medical topics and their potential value for the study of rituals, spiritual concerns, and political happenings, staple themes in cultural anthropology, seems to have had the effect of directing efforts toward systematic in-depth studies Young Most ethnographies concentrate on only certain aspects of comparative medicine, for example, aspects of beliefs or meanings of illness, and not on concrete aspects of healing.
Sometimes, the reverse is observed. Descriptive accounts predominate, making it difficult for one to evaluate how frequently a practice or an explanatory model is implemented. Ethnographers also differ in terms of orientation; some may prefer ritual aspects of healing, others semantic themes pertaining to illness, and still others the kinds of diseases that are encountered and their effects on the population. With respect to literate traditions of medicine, such as those of India, China, and Islam, anthropologists' efforts overlap with and parallel those of historians.
The anthropologists' interests obviously center on observed behaviors and contemporary practices, whereas those of historians center on what can be inferred from documents. The study of the social history of Western medicine has attracted a great deal of interest in the last fifteen years, far exceeding that of China, India, or Islam e. Nevertheless, social histories of medicine deal with beliefs and practices and frequently rely on concepts and perspectives developed in anthropology. A basic limitation of these studies is the lack of material on the actual dynamics of behaviors associated with sickness and healing in earlier historical epochs.
It is usually the case that important documents that reveal aspects of sickness and healing are translated and interpreted. Whereas this is indispensable for formulating some parameters, they simply do not address others. It is very likely that the actual processes of healing, including the kinds of organizations that may have existed among healers and the nature of relations between healers and their sick patients, are not recorded and may never be fully understood.go
Since much of the data collected on sickness and healing are contemporary in nature, be these of small-scale societies or pertaining to the "great traditions," the problem posed by the competing, often dominant biomedical tradition is vexing. It is difficult to separate native cultural perspectives on medicine from biomedical impositions.
The following questions illustrate this point. How much of a certain tradition's approach to healing is a result of the competition with or emulation of the biomedical? Were one to attempt to determine the kinds of sickness problems that a tradition handles "well," how is one to establish this if patients have resorted to other forms of healing? Since industrial capitalism is becoming the dominant political economic system in. These and related questions point to the kinds of data that are needed. A general theory about sickness and healing must overcome limitations in the quality and amount of data pertaining to medicine.
Its goal is to explain how the medical is configured in different types of societies and how it changes in response to social, ecologic, and historical considerations. The study of sickness and healing has been strongly influenced by contemporary biomedicine and its cultural presuppositions. Consequently, theory about medicine must incorporate biomedical insights but also strive to handle biomedicine as but one highly influential, to be sure cultural approach to medicine.
The approach to medicine in "pristine" societies not affected by biomedicine should ideally be given special consideration, although, as already noted, such types of societies are at best abstractions and approximations. In an analytic sense, one can delimit the medical as that which encompasses the problems of disease and injury in a society. However, this formulation immediately makes evident one's ethnocentric bias. Diseases as conceptualized in biomedicine and played out in contemporary societies are reasonably well demarcated. For the most part they are easily separated from the political, the legal, and the religious, as an example.
One who studies such phenomena comparatively, however, learns quickly that in many societies problems of sickness and healing are not separated from other concerns but blend imperceptibly with phenomena that in European, biomedicine-dominated societies are institutionally separated. Some problems in delimiting the medical in different societies can be illustrated. Many "diseases" of European societies may not be recognized or handled as sickness in other societies Fabrega ; Payer The personality disorders of psychiatry constitute good examples of this, although similar generalizations can be made about other "diseases.
However, that they can implicate traditional medical categories has been well documented Guarnaccia ; Jenkins ; Topley Another example is provided by misfortunes involving domesticated animals or crop failures. In many societies these are conceptualized and handled in ways that are very similar to misfortunes of human sickness. Obviously people are able to tell the difference between sickness and other misfortunes; however, the point is that ways of understanding these diverse problems and attempts to undo their consequences share a basic ontology and epistemology in the culture.
Something that an outsider might think of as "not medical" might be the. Conversely, in modern Anglo-European-influenced societies, problems of obesity, unwanted facial or scalp features, undesired gender characteristics, or what is judged as an unattractive bodily organ may be the object of medical treatment. In this case, it would appear that sickness of morale and satisfaction with self-image or social confidence underlie and motivate medical treatment.
In other words, something that would hardly be recognized as medical or sickness in many societies has taken on these labels in Anglo-European-influenced societies. Finally, one can consider other items of social behavior that flirt with the medical. In many small-scale, elementary societies, conventions pertaining to hunting, foraging, and harvesting are invested with sacred directives and rules that operate as safeguards against sickness and a host of other misfortunes, to be sure.
What one could term "the medical" thus appears to be spread out, intruding into the social, political, and economic. As a contrast, one can consider the profound effects on thoughts and behavior that have taken place in modern society as a result of the way public health officials promoted the germ theory of disease. A host of attitudes and behaviors toward the body, hygiene, and private functions were altered dramatically and medicalized as a consequence of learning about the germ theory of disease.
It is obviously the case that in these instances, also, the medical is spread out and intrudes into highly social and private spheres of human behavior. In both instances, then, one can say that the boundaries of the medical are problematized. The problem of delimiting the medical in society has to be viewed as part of the more general problem of reification of structures and entities as separate sorts of "things.
Human action and practice is reflexively under review and influenced constantly by knowledge that it essentially reproduces. Problems of sickness and healing are, of course, no different, yet for one intending a theoretical approach to medicine both conceptual categories and culturally organized behaviors need to be dealt with abstractly and formulated systematically.
The problem of delimiting the medical poses obvious difficulties for one intending to articulate a comprehensive yet unified theory. How can one be provided with a frame of reference and a set of concepts for integrating, analyzing, and comparing the way people in different societies instantiate sickness and healing if the material is so fluid and variable that it seems to militate against valid categorization?
There is, in fact, no way of avoiding these quandaries, although different strategies can be surmised. This epidemiological, public health approach has been undertaken and is not without its merits. However, since one starts out with a preconceived definition of the medical, one can only encompass phenomena covered by it and of necessity might have to exclude problems of sickness and healing that do not conform to biomedical definitions. The approach suggested here is to start with abstract definitions of what sickness and healing consist of viewed in biological, social and cultural terms and allow them to identify and locate the medical across societies and cultures.
Provided one is sufficiently specific, such a procedure can serve to delimit important areas of the domain of the medical that facilitate analysis. In this instance one may fail to include certain problems of disease viewed biomedically that are not conceptualized as problems of sickness and healing in a society.
However, if the diseases produce bodily symptoms, physical signs, or behavioral breakdowns, it is very likely that they will be conceptualized as sickness and dealt with accordingly in the society and culture. Many factors affect the level of sickness in a society. What one could term bioecologic factors have received most attention. Research has indicated that complex genetic structures of populations, the ecology of its physical habitat, its way of procuring and processing food and water, and the level of social organization of a society, including in particular the density of its population and its social institutions pertaining to the availability of fresh air and the disposal of wastes, are all important.
All of these and related factors will influence the level and kinds of disease that are prevalent, and the latter bear a direct relation to the level of experienced illness in the population and hence the impact of this in the from of sickness and healing on the members of the society. Were one to limit oneself to measuring the level of malaria or dysentery in a society, measures derived from epidemiology would suffice to assess impact of sickness.
However, were one to be interested in what sickness is made of as a social and cultural phenomenon, then what members of a population perceive as sickness and how they explain it, which entails orientations toward and understandings of the body and its functions as well as the problems of disease which reflect purely bioecologic factors , all are relevant.
What is important to emphasize is the role played by social and cultural factors in constructing and reconstructing sickness and healing. These factors can be conceptualized to operate more or less independently from the purely bioecologic ones pertaining to the epidemiology of disease and injury and to changes in physiology. In other words, even if sickness and healing are conceptualized as rooted in biological factors and as having evolutionary implications, one must still study them from a comparative standpoint as socially and culturally constructed.
Social Studies of Health, Illness and Disease: Perspectives from the Social - Google книги
There is much controversy here about how one is best to regard the biological and the cultural that will be dealt with in later chapters Barkow, Cosmides, and Tooby ; Bourdieu ; Giddens , , In the way of a generalization, if the social aspects of sickness and healing are emphasized, this means that the way in which they are thought of and played out in social conflicts or interpersonal relations can be studied comparatively with the strictly biomedical end of things kept separate. Moreover, a social and cultural framework allows one to consider under what conditions of social organization actors might be motivated consciously or unconsciously to express personal or social conflicts in sickness phenomena that are then played out during processes of healing.
In this instance, then, the degree to which sickness is played out socially and interpersonally, a practice factor, influences the level of perceived sickness and end points of treatment, a more cognitive one; and the actual pathology underlying all of this needs to be recognized but can be left out of the analysis. Other parameters of sickness and healing that reflect cultural meanings could be studied, for example, attitudes about the body or remunerative aspects of healing.
Finally, specific parameters of sickness and healing can be compared in different societies. In summary, sickness and healing have a form and content that are a function of society and culture. Societies and cultures are, of course, not unitary things, nor can eventuations of sickness and healing be regarded as homogenous and representative "entities" even if they were. These complexities need to be kept in mind whenever medical phenomena are dealt with in terms of social types.
Nevertheless, the interplay of cultural categories, social practices, and the reflexive, recursive nature of eventuations of sickness and healing need to be dealt with theoretically: Their diverse aspects in relation to types of societies need to be formulated and explained. A way of looking at sickness and healing comparatively so as to explain the diversity will be presented in later chapters.
An evolutionary perspective on behavior and adaptation, and, indeed, on the way physiological systems function, urges one to adopt a holistic, systems. In this light, an individual is judged to respond to environmental stress by means of changes in connected systems that describe him or her hierarchically. Sickness and healing as evolutionarily conditioned are thus constituted in a unity one could describe given our linguistic bias as psychosomatic and somatopsychic.
What this means is that there is a natural tendency for problems of adaptation to be manifested in terms of physiology, emotional experience, and behavior. Biomedical science and the intellectual tradition that spawned it have created an emphasis pertaining to sickness and healing that has been characterized as ontological Temkin The hallmark of sickness and the key target of healing is disease, a thing or object thought of as having a separate existence: an identity in anatomy, physiology, chemistry, and the like; a cause separated from itself; and an extension in time or "natural history.
A key logical corollary of the ontological emphasis is that the entities and processes that make up disease have a physical essence and of course come to occupy and take place in the physical body. Given this interpretation, disease is thought of as somehow different from things mental, behavioral, or psychological. Dualism thus seems to be entailed by the Western epistemology and ontology of disease. Dualism as a symbolic property of Western culture is structurally embedded in the contemporary practice of medicine. Since physicians are socialized with this bias, their clients are reinforced for it, a cultural bias that is widely prevalent in the society to begin with.
Dualism is thus a conditioning factor in the way sickness and healing are played out in Western society.