Disease and Its Meanings

Author(s): Warwick Anderson

Source: Health and History , Dec., 1999, Vol. 1, No. 4 (Dec., 1999), pp. 245-249
Published by: Australian and New Zealand Society of the History of Medicine, Inc

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ARTICLES

Disease and its Meanings

WARWICK ANDERSON

To recognise disease in ourselves or in others is to reflect, howev

fleetingly, on its moral significance. Our perceptions of disease ha
always prompted a search for attribution and responsibility;
more importantly they bring into focus the concerns we have abo
the way we live our lives, our relations to community, environme
and cosmos, and they challenge us to explain the purpose of m
function and suffering. Why me? - or why them? - and why no
we continue to ask. Hans Castorp, in Thomas Mann's The Ma
Mountain, discovered that 'all interest in disease and death is onl
an expression of interest in life'.1 We feel the full force of this o
servation perhaps only when we try to make sense of our own frai
Herve Guibert, in the last stages of AIDS, described 'an illness
stages, a very long flight of steps that led assuredly to death, bu
whose every step represented a unique apprenticeship. It wa
disease that gave death time to live and its victims time to die, tim
to discover time, and in the end to discover life.'2

A shorter version of this essay was published in the Lancet 2000, and I am grateful to
editors for their permission to republish those sections here. The essay benefited from
advice of Allan Brandt, Arthur Kleinman, Charles Rosenberg and John Harley Warner
1 . T. Mann, The Magic Mountain, trans. H. T. Lowe- Porter, Alfred A. Knopf, N
York, 1944, p. 495.
2. H. Guibert, To the Friend who Did not Save my Life, trans. Linda Coverdale, At
enaeum, New York, 1991, p. 164.

Health & History. 1999. 1: 245-249 245

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246 Warwick Anderson

In one sense, then, little has changed in a thousand years, but

much else has altered beyond recognition. Disease perception still
gives expression to personal, social and spiritual anxieties, but the
vocabulary we use has varied with time and place, and differed in
physical exactness and moral complexity.3
Until the last few hundred years, those who suffered and those
who sought to relieve suffering shared many assumptions about
the character of health and disease. The basic conceptual frame-
work seems to have been remarkably widespread. Bodies were con-
stantly in a state of ebb and flow with their environment, them-
selves changing and subject to the changes around them. Always in
a state of becoming, they were vulnerable to variations in activity,
diet, excretory function, sexual indulgence, season, climate and a
host of other behavioural and environmental factors. All change
was potentially pathological. The body in health existed in an easy
equilibrium with its circumstances; dis-ease was, as the word im-
plies, a systemic imbalance in intake and excretion, a disturbance of
function readily perceived by patient and doctor alike; the goal of
any therapy, therefore, was to restore equilibrium.4 Disease was
thus inseparable from individual temperament, or idiosyncrasy, and
one had to know the whole person, mind and body together, to
perceive the sickness. The experience and the words of the sick
individual necessarily were paramount. In this common culture of
disease perception, naturalistic explanation and moral commentary
jostled together. Illness, a bad or unhealthy condition of the whole
body, might develop in response to the change in seasons, or it
might be the result of abstinence or immoderate behaviour, the
consequence of natural disorder or a fall from grace. At the same
time as the body was an element of the natural world, and subject
to naturalistic explanation, it also found ambiguous expression in a
range of moral narratives.
As societies became more complex, elite groups of healers
emerged, and many of their theories and practices began to di-
verge from common intuitions of health and disease. The separa-
tion of disease diagnosis from the experience of sickness, and from

3. C. E. Rosenberg, Training Disease: Illness, Society and History', in C. E.

Rosenberg & J. Golden (eds), Framing Disease: Studies in Cultural History, Rutgers Uni-
versity Press, New Brunswick, 1991, pp. xiii-xxvi.
4. J. H. Warner, The Therapeutic Perspective: Medical Knowledge, Practice, and Pro-
fessional Identity in America, 1820-1885, Harvard University Press, Cambridge, Mass, 1986.

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 Disease and its Meanings 247

the circumstances of suffering, is perhaps most striking in Europe.

For more than two hundred years, doctors working in the Western
tradition have sought to localise disease within the body, to iden-
tify specific pathological lesions, first in organs, then tissues, then
cells, and now molecules. Increasingly, disease was perceived as sepa-
rable from the body as a whole; it could be recognised as a stand-
ard package, largely indifferent to individual idiosyncrasy; and it
might run its course without the patient ever experiencing it.5 Con-
versely, a person could now feel sick without fitting any validated
diagnostic category. During the past century or more, medical sci-
entists have successfully attached specific agency to this reductionist
pathology. A germ, toxin or gene can be held to account for most
ailments, while the importance of predisposition, bodily constitu-
tion, and social or environmental circumstances has diminished.6
The seed generally is more interesting than the soil. Disease has
thus become a thing that invades individual bodies and can move
between them, or else it arises unbidden within them, taking them
over. Bodies can be treated as little more than potential receptacles
for disease, uninteresting until infected. As the pathogenic agents
to which these alienated bodies succumb are usually invisible, and
since our experience of sickness has become so unreliable, we must
hope that medical experts will perceive our diseases. Even so, the
sicknesses that we feel may continue to exceed, to overflow, such
rationalistic inquiry.7
As modern biomedicine advanced in technical competence,
moral commentary did not disappear, but often it dwindled into a
simple and rather mechanistic attribution of blame, a form of mor-
alising.8 The onset of epidemic disease had always incited preju-
dice, permitting the stereotyping of foreigners, the poor, and other
races, as inherently disease-dealing and polluting.9 On contracting

5. O. Temkin, The Scientific Approach to Disease: Specific Entity and Individual

Sickness', in A. C. Crombie (cd.), Scientific Change: Historical Studies in the Intellectual,
Social and Technical Conditions for Scientific Discovery and Technical Invention from Antiq-
uity to the Present, Basic Books, New York, 1963, pp. 629^7.
6. W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century,
Cambridge University Press, Cambridge, 1994.
7. A. Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condi-
tion, Basic Books, New York, 1988.
8 . A. M. Brandt & P. Rozen (eds), Morality and Health, Routledgc, New York, 1997.
9. A. M. Brandt, No Magic Bullet: A Social History of Venereal Disease in the United
States since 1980, Oxford University Press, New York, 1985.

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248 Warwick Anderson

an epidemic disease, the victim often was rewarded with stigma

and segregation. Germ theories simply added pathological depth
to older social and political resentments: minorities might look clean
but who knew what transmissible threat lurked within? Now, of
course, we can trace individual responsibility for all disease, even
the most sporadic and trivial, much more precisely. What did the
individual do wrong? Smoke? Eat too much fat? Drink too much
alcohol? Have sex without a condom? Perhaps a more complex
moral narrative lies behind such a banal, if technically correct, cal-
culus of risk, but few practitioners seem competent to reflect on it.
In the past, we have known diseases of divine providence,10 dis-
eases of poverty,11 and diseases of civilisation,12 but most diseases
now are just diseases of innocent or guilty individuals - though the
notion of diseases of ecological destruction might yet provide a
new organising principle relating disease to the cosmos.13
During the past two hundred years or so, the historically rather
peculiar explanatory model of disease that developed in Europe
has become a global influence on disease perception. Just as we are
immersed in a global disease pool, so are we all exposed to some
degree to the insights of biomedicine. Its reductionist, technical
character makes it virtually context-free and has allowed an effica-
cious mass-production of disease diagnosis across the globe. And
yet, while standardised biomedical models may now dominate dis-
ease perceptions they do not go uncontested, even in European-
ised societies. The range of health belief is probably as broad as it
ever was, and many of the sick still find in alternative explanatory
models a more satisfying understanding of their illness.
Why should this be so? It seems almost as though, within bio-
medicine, our perception of disease has become so constrained by
our technical competence in diagnosing and treating malfunction,
that even as we invent an ever richer mechanistic vocabulary, we
are left with an ever more impoverished moral language. The ro-
mance of technology is so entrancing, and indeed so physically ef-

10. T. Ranger, & P. Slack (eds), Epidemics and Ideas: Essays on the Historical Percep-
tion of Pestilence, Cambridge University Press, Cambridge, 1992.
11. R. Dubos & J. Dubos, The White Plague: Tuberculosis, Man and Society, Little,
Brown, Boston, 1952.
12. C. E. Rosenberg, Pathologies of Progress: The Idea of Civilization as Risk, Bulle-
tin of the History of Medicine, vol. 72, 1998, pp. 714-30.
13. L. Garrett, The Coming Plague: Newly Emerging Diseases in a World out of Bal-
ance, Farrar, Strauss & Giroux, New York, 1994.

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 Disease and its Meanings 249

fective, that, as practitioners, we may be blind to the potential for a

moral structuring of disease, or we may simply believe that non-
technical explanation is none of our business. But many of those
who suffer from disease want, like Herve Guibert, to learn more
about their lives even if, as technically trained doctors, we cannot,
and perhaps should not, satisfy their demands. Charles Lamb once
observed that 'sickness enlarges the dimensions of a man's self to
himself'.14 Now, at the end of the millennium, we will tell our
patients that it's just a virus. 'Why me? Why now?' ask our patients,
and we stay not to give an answer.

University of Melbourne

14. C. Lamb, The Convalescent', in C. Lamb, The Last Essays ofElia> Little, Brown
& Co., Boston, 1892, p. 63.

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