I Dimensions of Health and Illness: Toward an Integrated Model Introduction The six chapters in this section emphasize the need to incorporate new dimensions into the prevailing definitions of illness and health. Although they employ numerous specific examples, all these articles focus on overall conceptualizations rather than on specific diseases. The different authors show how psychological, social, and cultural factors contribute to all phases of disease-its etiology, its manifestations, its treatment, and its prevention. The first chapter, by Ahmed, Kolker, and Coelho, reviews the background and limitations of the preponderantly medical definition of health, and the rationale for expanding the definition to include nonmedical dimensions. The authors point out that the medical profession has traditionally defined health as merely the absence of disease, and disease as an observable deviation from a biostatistical norm derived within a given historical experience and language system. They call attention to individual and cultural variations in the perceptions and conceptions of "sickness" and "wellness" held by given population groups. They further contend that both these concepts are more usefully viewed as complex behavioral entities consisting of psychological and sociocultural dimensions in addition to the biological ones. Contending that the new model provides useful guidelines for preventive action, the authors outline several socioenvironmental and behavioral forces that contribute to disease. They indicate that these forces may be largely controlled through preventive social, educational, and economic policies and through personal changes in life-styles. Thus, the most effective 1
2 Part I means to promote health, they claim, is through nonmedical preventive action, although the role of medical treatment should not be ignored. Echoing other calls for reforming the health care system (see Section V), they reiterate the need to decentralize and "humanize" health care and to place greater emphasis on socioenvironmental prevention. In the second chapter, Fabrega discusses the complex relationship between biological and cultural factors in the perception of illness and disease. In modern society, he contends, disease is a biomedical category, defined in terms of undesirable chemical or physical changes in the body's functioning. The interpretation of the organic changes, however, is culturally determined. The illness episode is experienced subjectively by the individual and by those around him. Fabrega mentions several adaptive functions of illness for individuals and for groups. These functions include calling attention to malfunctioning elements so corrective action (treatment) may be taken, sanctioning nonfulfillment of social roles, contributing to natural selection, and enhancing the functional unity of the group. Symbolically, the phenomenon of illness is linked to questions about the meaning of life and death and about the individual's relation to society. Furthermore, Fabrega continues, the group's formal body of knowledge about illness (its medical taxonomy), as well as its informal (folk) body of knowledge, are products of the cumulative cultural experience of the group and shape its medical care system. Thus, illness is a category of behavior appropriately studied by behavioral scientists and exhibiting wide cultural variations, although it is delimited by invariable biological structures and processes that are universal among human and nonhuman primates alike. According to Fabrega, the medical taxonomy of modern society, anchored exclusively in a biomedical frame of reference, deals only with disease as defined by "objective" changes in the organism. It therefore deprives individuals of the means for "interpreting" illness and death, for integrating them into their everyday context, and for coping with them psychologically and socially. Conversely, the fact that people are commonly sensitized only to "illness" (i.e., the presence of behaviorally compelling "symptoms" such as pain or incapacity) but not to "disease" (i.e., the presence or potential onset of certain biological processes) presents additional problems. There is little motivation to seek treatment or prevention in the absence of behavioral "symptoms", and thus the full benefits of the biomedical frame of reference are not achieved. In closing, Fabrega calls for an integration of the behavioral study of illness with the biological study of disease: "Illness constitutes a behavioral alteration that is physiologically and chemically grounded but socially and culturally conditioned." In the third chapter, K1einman further explores the sociocultural di-
Dimensions of Health and Illness 3 mensions of effective care. Reiterating the conceptual distinction between disease (the underlying biological or psychological malfunctioning) and illness (the culturally determined reaction to disease by the patient and by those around him), Kleinman cites case studies from his previous work in China and in the United States to illustrate variations in subjective meanings assigned to biological symptoms. Thus, for example, in Taiwan both patients and doctors categorize most psychological disorders as medical rather than psychiatric malfunctionings. Consequently, they will ignore psychological symptoms such as depression, and seek medical treatment only for somatic symptoms, although the latter may be psychologically caused. While the ethnomedical approach typically concentrates on the cultural construction of illness in other societies, Kleinman argues for a similar approach to the study of models of disease in our own society. He reminds us of the discrepancies between the biomedical model espoused by medical practitioners and the popular model held by patients and their families. Since the semantic meaning applied to illness determines the course of action taken by those involved, the failure of the physician to confront the personal and social meaning of disease may seriously undermine effective care. Kleinman calls for the integration of personally and socially relevant meanings, alongside the biomedical meanings, into both medical science and health care. He offers guidelines for eliciting the patient's and his family's" clinical reality" as a basis for prescribing effective care. However, he realistically notes the political difficulties that will stand in the way of any extensive restructuring of the health professions. The fourth chapter, by Young, contrasts the drawbacks of the Western medical model with the concrete, although limited, advantages of indigenous medical systems in traditional societies. Young discusses several dimensions of medical rationality. A key dimension is efficacy, i.e., the ability to produce desired results (empirical efficacy), or to organize and manage the circumstances connected with illness (symbolic efficacy). He points out that indigenous medical systems are often nearly as empirically efficacious as Western medicine. He offers several hypotheses to account for this efficacy, including the self-limiting nature of many sicknesses and the common practice of using Western medicine only as a last resort after traditional medical treatment has failed and the case is more or less hopeless. Furthermore, indigenous medical practices are often symbolically efficacious in that they enable people to manage sickness episodes and to orient themselves to threats of illness within the cultural context. In discussing the limitations of Western medicine, Young points out that while Western medical science is dominated by scientific standards of proof, Western medical practice does not meet the same standards of scien-
4 Part I tific rationality. This is 50 because clinical decisions are often constrained by insufficient information and by extraneous considerations such as professional interests. Another drawback of Western medicine is the low productivity inherent in the curative approach-i.e., the fact that it provides adequate medical services primarily for the elite, while contributing little toward optimizing the health of the greatest number of people. While Young does not propose any concrete alternatives to the Western medical system, he notes the existing juxtaposition in many societies of Western and traditional medicine. He points out that a practical division of labor and an interchange of ideas and practices between them may be advantageous to all the people served. In the fifth chapter, a paper prepared by the World Health Organization (WHO) for the World Health Assembly in 1977, the writers summarize briefly what is known today about the role of sociologicat psychologicat and cultural factors in the incidence, the course, and the outcome of disease, and propose guidelines for applying this knowledge to WHO's health programs and policies. For example, we know that low socioeconomic status is correlated with shorter life expectancy; that rapid cultural and social change is correlated with stress and hence with hypertension and cardiovascular disorders; that the severity of mental illness and the probability of recovery depend on the degree of cohesive support forthcoming from the patient's family; and that alcoholism and drug addiction are influenced by psychologicat sociat and cultural factors. The authors outline the implications of this knowledge for health policy and practice. They point out the need for training health workers in the behavioral sciences, for incorporating the beliefs and practices of indigenous communities into the health care process, and for coordinating medical efforts with efforts in other sectors in order to achieve maximum benefits for health. The sixth chapter, by Ahmed and Kolker, asserts that in order to meet WHO's goal for world health, a new approach is needed to health planning in developing countries. This approach, based on Young's thesis presented in the fourth chapter, consists in shifting the emphasis of health delivery to the level of the rural community and in integrating traditional health practitioners into the health delivery system. The WHO's goat originally set in 1946, asserted the fundamental right of all people to u a state of complete physicat mental and social well-being. u While the authors admit that this goal is frankly idealistic, they point out that massive international aid in the past three decades has failed to bring the health level of developing countries to that of industrialized nations. The reasons for this failure, the authors indicate, include the relatively permanent shortage of trained manpower, the staggering costs of Western technology even when it is nominally free, the variety of new and unantici-
Dimensions of Health and Illness 5 pated problems created by Western technology, and perhaps most crucially, the cultural incompatibility between the Western medical model and native medical traditions. The authors discuss the limitations of the Western medical model-in particular its tendency, in its more extreme manifestations, to exclude the cultural, psychological, and social dimensions of health. By contrast, non Western medical systems view health as a state of harmony between the body, the soul, and the cosmos. The authors underline some often-overlooked functions of traditional medicine, including convenience, affordability, the relief of anxiety, the involvement of family and community, and mediation between the worlds of tradition and modernity. They call for integrating the resources of traditional medicine into the health delivery system in order to bridge the gap between the goal-optimal health for all people-and the currently available means.