The Relevance of Social Science for Medicine (Culture,

Illness and Healing, 1)

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 THE RELEVANCE
OF SOCIAL SCIENCE
FOR MEDICINE

Edited by

LEON EISENBERG
Harvard Medical School, Boston

and

ARTHUR KLEINMAN
University of Washington, School of Medicine,
Seattle

D . REIDEL PUBLISHING COMPANY

DORDRECHT : HOLLAND / BOSTON : U.S.A.

LONDON : ENGLAND
 library of Congress Cataloging in Publication Data

Main entry under title:

The Relevance of social science for medicine.

(Culture, illness, and healing)

Includes bibliographies and index.
1. Social medicine. I. Eisenberg, Leon, 1922-
II. Kleinman, Arthur.
III. Series. [DNLM: 1. Sociology, Medical. WA 31 R382)
RA418.R44 362.1 80-24965
ISBN-13: 978-90-277-1185-4 e-ISBN-13: 978-94-009-8379-3
DOl: 10.1007/978-94-009-8379-3

Published by D. Reidel Publishing Company,

P.O. Box 17, 3300 AA Dordrecht, Holland.

Sold and distributed in the U.S.A. and Canada

by Kluwer Boston Inc.
190 Old Derby Street, Hingham, MA 02043, U.S.A.

In all other countries, sold and distributed

by Kluwer Academic Publishers Group,
P.O. Box 322, 3300 AH Dordrecht, Holland.

D. Reidel Publishing Company is a member of the Kluwer Group.

All Rights Reserved

Copyright © 1981 by D. Reidel Publishing Company, Dordrecht, Holland
No part of the material protected by this copyright notice may be reproduced or
utilized in any form or by any means, electronic or mechanical,
including photocopying, recording or by any informational storage and
retrieval system, without written permission from the copyright owner
 T ABLE OF CONTENTS

PREFACE ix

1. LEON EISENBERG and ARTHUR KLEINMAN I Clinical Social

Science

SECTION 1: HOW ACADEMIC PHYSICIANS VIEW

THE SOCIAL SCIENCES

2. ROBERT G. PETERSDORF and ALVAN R. FEINSTEIN I An

Informal Appraisal of the Current Status of 'Medical Sociology' 27

SECTION 2: SOCIAL SUPPORTS:

INFLUENCES ON HEALTH AND ILLNESS

3. LISA F. BERKMAN I Physical Health and the Social Environment:

A Social Epidemiological Perspective 51
4. JOHN B. McKINLAY I Social Network Influences on Morbid
Episodes and the Career of Help Seeking 77

SECTION 3: ILLNESS BEHAVIOR

5. ANDREW C. TWADDLE I Sickness and the Sickness Career: Some

Implications III
6. MARILYN BERGNER and BETTY S. GILSON I The Sickness
Impact Profile: The Relevance of Social Science to Medicine 135
7. GILBERT LEWIS / Cultural Influences on Illness Behavior:
A Medical Anthropological Approach 151

SECTION 4: CULTURE, MEANING, AND NEGOTIATION

8. BYRON J. GOOD and MARY-JO DELVECCHIO GOOD / The
Meaning of Symptoms: A Cultural Hermeneutic Model for Clinical
Practice 165
9. JOHN-HENRY PFIFFERLING / A Cultural Prescription for
Medicocentrism 197
10. JOHN D. STOECKLE and ARTHUR J. BARSKY / Attributions:
Uses of Social Science Knowledge in the 'Doctoring' of Primary
Care 223
vi T ABLE OF CONTENTS

11. IRVING KENNETH ZOLA / Structural Constraints in the Doctor-

Patient Relationship: The Case of Non-Compliance 241
12. WAYNE KATON and ARTHUR KLEINMAN / Doctor-Patient
Negotiation and Other Social Science Strategies in Patient Care 253

SECTION 5: SOCIAL LABELING AND

OTHER PATTERNS OF SOCIAL COMMUNICATION

13. NANCY E. WAXLER / The Social Labeling Perspective on Illness

and Medical Practice 283
14. LINDA ALEXANDER / The Double-Bind Between Dialysis Pa-
tients and Their Health Practitioners 307

SECTION 6: SOCIOPOLITICAL AND

SOCIOECONOMIC ANALYSES

15. HOWARD WAITZKIN / A Marxist Analysis of the Health Care

Systems of Advanced Capitalist Societies 333
16. M. HARVEY BRENNER / Importance of the Economy to the
Nation's Health 371

LIST OF CONTRIBUTORS 397

NAME INDEX 399

SUBJECT INDEX 406

To Carola and Joan
 PREFACE

The central purpose of this book is to demonstrate the relevance of social science
concepts, and the data derived from empirical research in those sciences, to
problems in the clinical practice of medicine. As physicians, we believe that the
biomedical sciences have made - and will continue to make - important con-
tributions to better health. At the same time, we are no less fIrmly persuaded
that a comprehensive understanding of health and illness, an understanding
which is necessary for effective preventive and therapeutic measures, requires
equal attention to the social and cultural determinants of the health status of
human populations. The authors who agreed to collaborate with us in the writ-
ing of this book were chosen on the basis of their experience in designing and
executing research on health and health services and in teaching social science
concepts and methods which are applicable to medical practice.
We have not attempted to solicit contributions to cover the entire range of
the social sciences as they apply to medicine. Rather, we have selected key ap-
proaches to illustrate the more salient areas. These include: social epidemiology,
health services research, social network analysis, cultural studies of illness
behavior, along with chapters on the social labeling of deviance, patterns of
therapeutic communication, and economic and political analyses of macro-social
factors which influence health outcomes as well as services. Particular emphasis
is placed on patient-oriented teaching of social science in clinical training
programs, teaching which attempts to translate knowledge and skills from
anthropology and sociology in order to conceptualize sickness more adequately
and to care for patients more successfully. We have chosen the chapters to
reflect distinctive, clinically relevant examples of this new and potentially very
important fIeld of research.
We have in mind a primary audience of medical and other health science
students, physicians and other health workers in practice, and clinical investi-
gators and teachers who wish to learn what is relevant in social science. We have
asked our contributors to write for such an audience and where possible to spell
out the practical significance of their work. While the chapters vary in their
accessibility to a clinical audience, we believe all of them can be read with profIt
and that many will have immediate value for the applied interests of clinicians.
In addition, we believe that a number of the chapters in this book will be of
use to social scientists whose fIeld of interest includes health and the health
professions.
The Editors share the view that social science has much to contribute to
medicine, but that its practical implications need to be more precisely defined;
strategies must be developed by which the new understanding can be more
ix
L. Eisenberg and A. Kleinman (eds.), The Relevance of Social Science for Medicine, ix-x.
Copyright © 1980 by D. Reidel Publishing Company.
x PREFACE

effectively applied in medicine's distinctive domains. The chapters that follow

disclose both successful examples and the difficulties in the process of transfer
across disciplines. While some of the obstacles to this process arise within medi-
cine, others emanate from social science. Although this volume does not pretend
to have provided a recipe for the removal of these barriers, we believe that some
of the major problems facing the integration of social science within medicine
are identified and experiences in efforts to resolve them are shared.
Quite clearly, there is at present no rigorous and systematic means for decid-
ing what is most relevant, how it can be applied and how its efficacy can be
assessed. In the absence of a common agreement on strategy, the best. that we
can do is to share "state of the art" experiences and to compare outcomes
critically. Many of the chapters in this book will advance this process and there-
by indicate to readers significant directions for future collaboration. At the same
time, others suggest (either explicitly or tacitly) where the limits of social science
contributions may lie.
In preparing a book for a non-specialist audience, we have attempted to avoid
lengthy expositions of highly technical questions of interest primarily to the
separate social science disciplines themselves. At the same time, this is no mere
primer. We take our readers seriously and ask them to join us in confronting
issues at the critical juncture of sociology and anthropology with health prob-
lems. We hope that the chapters will be sufficiently exciting that readers will
be impelled to use the extensive bibliographies appended to them in order to
consult original sources as well as general reviews.
The Editors wish to acknowledge the outstanding secretarial assistance of
Carla Millhauser and Marge Healy, and the editorial assistance of Leslie Morris.
We would also like to thank our students and colleagues at Harvard and at the
University of Washington whose sometimes jaundiced responses to our own early
efforts to relate social science to medicine prompted the concerns which resulted
in the creation of this volume. The undergraduate and graduate students who
attended our seminars and conferences most always took the position: "I'm
from Missouri; prove it to me." While we did not always succeed, the demand
to "prove it" resulted in sharpening our own awareness of the limits of our
understanding and of the need for a clearer and more logical exposition of what
we thought we understood. We hope they profited from our interchange; we
know we did.

Boston and Seattle LEON EISENBERG

April 1980 ARTHUR KLEINMAN
 LEON EISENBERG AND ARTHUR KLEINMAN

1. CLINICAL SOCIAL SCIENCE

IS MEDICAL PRACTICE IMPEDED BY "TOO MUCH SCIENCE"?

In the three and a half decades since the Second World War, there have been
remarkable gains in the effectiveness of preventive and therapeutic measures in
medicine. To mention but a few examples of the former: vaccines which can
prevent poliomyelitis, rubella and measles; Rho (D) immune human globulin
administered to Rh negative mothers at the birth of an Rh positive infant to
prevent sensitization of the mother and hemolytic disease in subsequent children;
screening measures leading to appropriate management to minimize the conse-
quences of inherited metabolic disorders; and prenatal diagnosis to assure a
normal birth. As examples of the latter, consider only: antibiotic treatment of
infectious diseases; diuretics and alpha blockers to control hypertension; open
heart surgery to correct valvular defects; total hip replacement; chemotherapy
for childhood leukemias; drugs capable of aborting acute psychotic episodes and
of minimizing their recurrence. To a medical graduate of the mid-1940's who has
seen these changes during his own professional lifetime, the new capabilities are
a continuing source of wonder and gratification.
Despite the physician's daily observation of impressive results from modern
treatments, it is a different matter to ask how far these treatments can be given
credit for the improvements in the general health of the U.S. population over the
same time period. Life expectancy for males, which was 64.4 years at birth in
1946 had increased to 69.3 years by 1977; the corresponding figures for females
went from 69.4 to 77.1 (National Center for Health Statistics 1978, 1979).
Some measures, no matter how effective for the particular patient, address
disorders which are rare (dietary treatment for phenylketonuria, for example,
improves the quality of life for one in eleven thousand live born infants); others,
like total hip replacement, have little effect on mortality despite dramatic bene-
fit for function; even those which are life-preserving may not add appreciably to
longevity because the diseases they combat occur in the elderly who die not long
after from other causes.
It is undoubtedly true, as McKeown (1976) has argued, that the incidence of
many infectious diseases had begun to decline in the last century well before
the introduction of contemporary treatments because of improved sanitation,
nutrition and general living conditions, tuberculosis being a notable example.
Nonetheless, the further decline of these once-dreaded ailments has been measur-
ably hastened by chemotherapy (McDermott 1977). For example, over the past
20 years, the mortality rate for tuberculosis fell from about 60/100,000 in
1947, the year chemotherapy was introduced, to about 6 in 1967. If the rate

L. Eisenberg and A. Kleinman (eds.), The Relevance of Social Science for Medicine, 1-23.
Copyright © 1980 by D. Reidel Publishing Company.
2 LEON EISENBERG AND ARTHUR KLEINMAN

of change in the curve had remained the same for that 20 year period as it had
been for the earlier years of this century, the expected death rate would have
been five times as large. Changes in the death rate from tuberculosis in New
Zealand both among the Maori (from 300 to 15) and among Europeans (from
30 to 3) show similarly increased benefits, despite the very marked differences
in living conditions between the indigenous and the Caucasion populations
(McDermott 1977). Furthermore, it is the vaccines against polio, measles and
rubella which alone account for the marked reduction in the incidence of these
diseases in the United States. If medicine cannot claim sole credit for the tenfold
reductions since 1900 in infant and child mortality and for the threefold reduc-
tion in adolescent and young adult mortality (Surgeon General 1979), the
evidence is persuasive that it has made an important contribution to these gains.
Mortality statistics understate the contribution of modern therapeutics to
patient welfare. Relief of pain and enhancement of function in individuals with
chronic disease may yield few cures and little detectable effect on longevity but
the gain in quality of life for the millions of individuals at risk has been sizable.
Death is, after all, inevitable. The prolongation of life, by whatever means,
inescapably brings with it a higher prevalence of the degenerative diseases of
old age for which palliation rather than cure is the most likely outcome of the
physician's efforts (Gruenberg 1978).
Yet, despite the impressive gains which have resulted from the application of
biomedical science to the understanding and control of disease, the American
public views itself, in John Knowles' (1977) pithy phrase, as "doing better and
feeling worse." At least, this is what one would conclude from the chorus of
articulate critics of medicine. It is not altogether clear that the dissatisfactions
expressed in the journals of opinion are an accurate reflection of the attitudes
of the general public who like their own doctors at the same time they have
reservations about medicine as an institution. In a recent opinion poll conducted
by the Center for Health Administration Studies at the University of Chicago,
88% of Americans reported general satisfaction with the care they receive,
although 61 % simultaneously believe that there is a "general crisis in health
care" (Johnson Foundation 1978).
When complaints are registered, they include: escalating costs; maldistribution
of physicians; disappearance of the house call and its replacement by the trip to
the emergency room; fear of iatrogenic disease produced by new diagnostic and
treatment methods; and resentment at treatment failures, a resentment which is
all the greater because of the expectations aroused by pUblicity about each new
"breakthrough." These complaints converge on the conviction that today's
doctors are less responsive to the personal needs of their patients than the old-
fashioned family doctor is thought to have been.
It has become the conventional wisdom that the increased dissatisfaction, in
the face of the manifest improvement in medical effectiveness, stems from the
very success of technological achievement. Doctors, it is alleged, have lost the
human touch precisely because their preoccupation with laboratory tests and
 CLINICAL SOCIAL SCIENCE 3

technical fixes obscures their awareness of the patient as a person. Is there

evidence for the proposition that doctors are less sensitive to patient needs
because they are more competent in curing disease? We do not argue that doctors
are as responsive to personal and social needs as they should be; indeed, concern
about that problem lies behind the writing of this book. The question we raise
is this: were doctors ever the compassionate, humane and wise figures nostalgia
would have us believe they once were? We are not persuaded that such was the
case.
What Were the "Good Old Days" Like?
From classical antiquity (Edelstein 1967) to the present (Sigerist 1958), there
have been outstanding medical practitioners who knew what was to be known,
individualized the care they provided and were actuated by the highest ethical
standards of the time. They have left us a legacy of eloquent treatises on medical
practice; but these shining moments in the historical record do not represent the
performance of the generality of their contemporaries. During the eighteenth
and nineteenth centuries, medicine in England and America was practiced by
doctors of every stripe and persuasion, rigid in their adherence to the tenets of
a particular school of thought, varying in the degree of their acquaintance with
the scientific knowledge of the day. King (1958) has provided an example of
the rancor of the quarrels and the bitter competition between physicians by
extracts from a pamphlet consisting of an exchange of defamatory letters be-
tween William Withering (the discoverer of the diuretic properties of foxglove
in cardiac edema) and Robert Darwin (the father of Charles). Withering had
infuriated the 22 year-old Darwin, one year out of medical school, by taking
over the care of the latter's patient, arriving at a new diagnosis and changing the
treatment radically. Wrote Dr. Darwin:
Every liberal person sees through the paltry motives which have always induced you to
slander those of your own professions, among the other mean arts by which you attempt
to support your business.

Replied Dr. Withering:

That I have slandered you ... is untrue ... As I could not protect you in any way in which
I ever wished to cover the errors of a young physician, I could not, in justice to myself and
my patients, act otherwise than I have done.

Rejoined Darwin:
You are one of those characters of whom the enmity is far less dangerous than the friend-
ship.

Riposted Withering:
Possessed, therefore, as I am of self-satisfaction, of the good opinion of the world at large
and of medical men in particular, your enmity or your friendship, your good or your bad
opinion, are to me equally insignificant.
4 LEON EISENBERG AND ARTHUR KLEINMAN

English novels of the nineteenth century make evident the ambivalence toward
medical science by their emphasis on the demonic character of the physician-
investigator (Millhauser 1973). Just how far the French physician of that period
embodied empathy for the patient can be inferred from the passage in the last
chapter of Balzac's Pere Coriot written in 1834; the medical student Bianchon,
in reassuring his friend Rastignac that he cares for the dying Goriot, comments:
"Doctors already in practice see only the [disease]; I can still see the sick man,
my dear boy."
American medicine of the nineteenth century went from a cycle of bleeding
and purging to what some condemned as therapeutic nihilism; advocates of each
school roundly condemned the others (Rosenberg 1979). One American news-
paper of the mid century condemned "poisoning and surgical butchery;" another
large daily declared that the whole medical guild was "a stupendous humbug"
(Shryock 1947). There were, of course, amidst the polemics, compassionate
physicians who responded in a very human way to the tragedies they faced.
Rosenberg (I979: 11) quotes from the diary of Dr. Samuel W. Butler in 1852
in which Butler recorded his response to the unexpected death of a child he had
been treating:
Remedies altho' slow in their action, acted w.ell but were powerless to avert the arm of
death. The decrees of Providence ... cannot be set aside. Man is mortal, and tho' remedies
often seem to act promptly and effectually to the saving of life - they often fail in an
unaccountable manner! 'So teach me to number my days that I may apply my heart unto
wisdom.'

Nonetheless, what is noteworthy is how acerbic the quarrels continued to be

even as the century reached its end. Abraham Jacobi, the fust President of the
American Pediatric Society, protested in 1908:
Expectant treatment is often a combination of indolence and ignorance ... It is the sin of
omission, which not infrequently rises to the dignity of a crime.

Yet Sir William Osler (I920), speaking at the Johns Hopkins Historical Club in
1901 asserted that the great accomplishment of the new school of medicine was:
... firm faith in a few good, well tried drugs, little or none in the great mass of medicine
still in general use. Imperative drugging - the ordering of medicine in any and every malady
- is no longer regarded as the chief function of the doctor.

These excerpts, it is important to recall, are from the writings of distinguished

physicians. What can be said about the generality of practicing doctors?
Abraham Flexner (I 9 10), in his Report on Medical Education in the United
States and Canada, commented:
The profession has been diluted by the presence of the great number of men who have
come from weak schools with low ideals both of education and of professional honor
(p. xiv) ... We have indeed American practitioners not inferior to the best elsewhere; but
there is probablY no other country in the world in which there is so great a distance and so
fatal a distance between the best, the average and the worst (1910:20).
 CLINICAL SOCIAL SCIENCE 5

The Flexner Report was to transform medical education by its recommen-

dations for a four year curriculum, a full time facuity, clinical clerkships, the
incorporation of medical schools within universities and the introduction of
research into the teaching program. Within a decade of its publication, one-third
of the existing medical schools closed their doors and the number of graduates
in 1919 fell to half of what it had been at the turn of the century, a level it
would not achieve again until after World War II (Richmond 1969). Nonetheless,
struggles between the clinician and the laboratory scientist continued. Sir James
MacKenzie (1919), an outstanding cardiologist, wrote:
Laboratory training unfits a man for his work as a physician, for the reason that, not only
does the laboratory man fail to educate his senses, but he puts so much trust in his mechan-
ical methods that he never recognizes their limitations and he fails to see that there are other
methods which are essential to the interpretation of disease.

Alfred E. Cohn (1924), founding Editor of the Journal of Clinical Investigation,

distinguished sharply between the bacteriology laboratory, remote from the
bedside, and the contributions of the clinical investigator:
Dependence on the outside world (i.e. on the bacteriologist) for solution of its problems is
in part a reproach to medicine ... The task which academic medicine in the United States,
now become self-conscious, has set itself ... is the task of Clinical Investigation.

Cohn (1928) insisted that:

The history of medicine since the Renaissance has shown plentifully that whenever the
approach to an understanding of disease is made by scholars trained primarily in the other
pursuits of knowledge ... the result, so far as understanding disease is concerned, is dis-
appointing and sometimes grotesque.

Perhaps the most eloquent defense of the physician's clinical skills and their
importance for patient care, is to be found in the writings of Francis W. Peabody
(1930), Professor of Medicine at Harvard and Chief of the Fourth Medical
Service of the Boston City Hospital, to whom we owe the moving words: "The
secret of the care of the patient is in caring for the patient" (1930:57). In
describing the attitudes of his medical contemporaries in 1927, he wrote:
The most common criticism made at present by older practitioners is that young graduates
have been taught a great deal about the mechanism of disease, but very little about the
practice of medicine - or to put it more bluntly, they are too 'scientific' and do not know
how to take care of patients (1930:27).

Commenting on public attitudes, he noted:

The layman of the older generation, who has been disappointed in his medical experience
and who feels that something has been lacking in the way of warmth, sympathy and under-
standing of his case as a whole, is very apt to hark back to earlier days. 'What we need,' he
says, 'is a general practitioner!' (1930:7).

Thus, the tension between "science" and "care" was already present in the early
stages of the thrust toward specialization, well before specialty boards were
6 LEON EISENBERG AND ARTHUR KLEINMAN

formally organized. Peabody argued forcefully for the role of the general prac-
titioner:
The more a doctor knows of his patient's general background, the greater advantage he has
in handling the case . .. [The general practitioner) knows the patient from childhood up
- his physical health, the nervous and mental strain to which he has been subjected, the
conditions of his social, business and domestic life, and more even than this, he may have
the same detailed knowledge of the patient's parents and of the circumstances of their lives
. .. The only person who can really gather together this fundamental knowledge of his
patients is the general practitioner (1930:24-25).

Peabody's comments illuminate two issues. First, contentions that there is

too little care because of too much science antedate today's era of high tech-
nology by 50 years; second, the virtues of the family doctor which Peabody
spoke for so eloquently stemmed, when they were present, from continuing
intimate acquaintance with patient, family and community, and not from medi-
cal theory or education. To a considerable extent, those virtues resided in the
doctor's role in an America of family farms, small towns and multigenerational
families. Generalist or specialist, the physician no longer has the opportunity
to come to know the extended family for several generations, now that one in
five American families moves each year; familiarity with "the conditions of the
patient's social, business and domestic life" is no longer readily available to even
the so-called neighborhood doctor now that our population has shifted to a
predominantly urban locus, with its anonymity, fragmentation and weakening
of identification with a neighborhood. Moreover, few doctors are likely to spend
their medical lifetimes in one place.
Not quite ten years after Peabody's remarks, L. J. Henderson, Professor of
Biological Chemistry at Harvard Medical School, issued a call for a theory to
guide the physician in understanding doctor and patient as a social system.
Henderson (1936) reminded the leaders of academic medicine that the Hip-
pocratic tradition had emphasized a:
general view of the patient as a human being living in an environment that is social as well
as physical. All this is particularly due to a clear appreciation of restrictions on mere tech-
nology in practice. It leads to the perception that in the practice of medicine there is much
beyond mere technology (1936:8).

In his view, the grand accomplishments of laboratory science had "defeated the
clinical party" and had brought about a condition:
in which the patient is ... often a mere case which (not who) passes through the doctor's
office, his past, present and future unknown, except within the meager abstractions of
etiology, diagnosis and prognosis; and his personality and relations with other persons not
even thought of (1936:9-10).

Henderson emphasized the necessity for:

somebody to understand and treat real men and women, not mere medical, surgical or
social cases (1936: 10).
 CLINICAL SOCIAL SCIENCE 7

He contended that:

when the ancient and empirical methods of acquiring a skill have lost their efficacy, there
seems to be only one way of recovering what has been lost. This is through scientific for-
mulation (p. 10) ... There is scientific sociologic knowledge that can be applied by anyone
who possesses a native capacity for the skilled management of his own relations with others
and for understanding the role of human beings in the everyday world. Being scientific, such
knowledge can be stated clearly and generally. It can therefore be taught and, within narrow
limits, applied (1936:11).

Henderson (1935) believed that Pareto's sociology provided such a scientific

theory. Whether or not Pareto's formulations constitute an adequate basis for
conceptualizing "the role of human beings in the everyday world," what is
pertinent to this discussion is Henderson's injunction to physicians that:

a physician and a patient taken together make up a social system ... In any social system
the interaction of the sentiments is likely to be at least as important as anything else (p. 14)
... The doctor must not only appear to be but must really be interested in what the patient
says ... In an interview listen, fust, for what the patient wants to tell, secondly, for im-
plications of what he does not want to tell, thirdly, for implications of what he cannot tell
(p. 17) ... Beware, then, when talking to a patient, of your own arbitrary assumptions, of
your own beliefs, of your own feelings (p. 18) ... If physician and patient constitute a
social system, it is almost a trivial one compared with the larger social system of which the
patient is a permanent member and in which he lives. This system, indeed, makes up the
greater part of the environment in which he feels that he lives. I suggest that it is impossible
to understand any man as a person without knowledge of this environment and especially
of what he thinks and feels it is; which may be a very different thing (1935:20).

TRADITIONAL HEALERS AND HOLISTIC MEDICINE:

THE MYTH OF THE GARDEN OF EDEN

One further digression is necessary before we take up Henderson's avowal of

the importance of "scientific sociologic knowledge" for medical practice. As
anthropologic studies of cultures exotic to the West have become part of popular
lore, the romantic myth has arisen that traditional healers possess the very
understanding of patient care which is lacking in Western medical practice.
Precisely because we advocate the value of anthropologic methodology for a full
understanding of the doctor's role, it is necessary to clearify just how far this
belief is warranted. Irrelevant to our present concern is the extent to which
herbal remedies (Indian: rauwolfia; Peruvian: quinine; Chinese: ephedrine; Greek
and Arabic: morphine) have been shown (and others will be shown) to represent
the empirical discovery of active principles which, when further purified by
pharmaceutical chemistry, are incorporated into the modern pharmacopeia.
What matters to this argument is the set of therapeutic relationships and rituals
which characterize the forms of traditional medicine still to be found in develop-
ing countries and which are thought to represent major integrative forces within
the community.
If this thesis holds at all, it is true primarily for those small groups of hunter-
8 LEON EISENBERG AND ARTHUR KLEINMAN

gatherers and early agriculturalists, so remote geographically that they have been
largely isolated from contact with other cultures and so continue to adhere to a
central cosmology unchallenged by competing beliefs. Turner (1967) has expli-
cated the Ndembu healer's view of illness as a manifestation of dissonance within
the social order and therapeutic rituals as means to resolve conflict and reaffirm
threatened cultural values. Many societies, like the Dobuans (Fortune 1932), are
full of suspicion, ill will and treachery. Illness beliefs and healing rituals are
central to the maintenance of cohesion. Since shamans and other sacred folk
healers frequently can cause illness (via sorcery) as well as treat it, the threat of
sorcery and the strongly negative feelings that attend it give healers unusual
power over patients - power that may effectively silence patients' dissatisfaction
and leave them without therapeutic recourse (Kleinman 1980 :240). The belief
in sorcery as a major cause of illness can wreak havoc when the epidemiology of
disease is not at a steady state and therefore "control" by magic fails.
Lindenbaum (1979) has provided a graphic account of the crisis provoked by
the spread of kuru among the Southern Fore in the Eastern Highlands of Papua
New Guinea. Kuru is an invariably fatal, slowly progressive disease of the central
nervous system, caused, in the Western meaning of cause, by an atypical neuro-
tropic virus (Gajdusek and Gibbs 1975). In the medical classification scheme of
the Fore, kuru is one of a group of diseases caused by the malicious actions of
human sorcerers. Accordingly, the appropriate response to the onset of the
disease is to summon a curer to identify the sorcerer and offset his malignant
influences by appropriate magical remedies. As the pandemic intensified, accusa-
tion and suspicion mounted; curers themselves were denounced as frauds because
their rituals failed to heal; villages turned against one another; warfare was
imminent. Unable to control the disease at the local level, the Fore assembled
in mass meetings known as kibungs. Sorcerers were publicly reproached for
crimes against society and urged to confess their misdeeds; some public "con-
fessions" were indeed elicited. Speakers called for brotherhood and unity:

Our ancestors were the same. We living men are the ones who split apart and gave separate
names to our groups. At this kibung let us adopt the customs of our ancestors. We will
stop making kurn on our own people. Ibubuli is our all-inclusive name (1979: 104).

The kibungs served to minimize internecine warfare but they too fell into disuse
as the disease persisted. It was only when modern virology had identified agent
and mode of transmission and when modernization and civil regulation gradually
transformed the social customs of the Fore that kuru was controlled; transmis-
sion was intercepted by ending the practice of ritual cannibalism as a rite of
mourning and respect for dead kinsmen.
In most, if not all, developing countries, no single world view predominates.
Rather, there are sets of competing ideologies which have resulted from com-
merce between cultures and different degrees of access to specialized knowledge.
The notion that healer and patient are united by a common cosmology is
belied by the presence of many contradictory belief systems; most sick persons
 CLINICAL SOCIAL SCIENCE 9

are pragmatists and are willing to consult, either simultaneously or in succession,

a series of healers with divergent methods. For example, Crapanzano (1973) has
studied the disease theory and therapeutic practices of the Hamadsha brother-
hood (an order of Islamic Sufism). The cause of disease is jinn (spirit or devil);
the task of the healer is to drive thejinn out or, failing that, to establish a work-
ing relationship with it. However, a contemporary Moroccan may also turn for
help when ill, not merely to the Islamic brotherhoods (Hamdushiyya, Gnawiyya,
Isawiyya, Rahaliyya and Jilaliyya) but also to fuqaha (Koranic teachers who
write amulets and talismans), herbalists, specialists in traditional Arabic medi-
cine; aguza (old women familiar with magical brews and midwifery); and exor-
cists. Along side these traditional healers are Western medical practitioners, each
with stylistic and social class differences: European physicians; Western-trained
Morrocans; pharmacists; male nurses; European missionaries; and local infirmaries
and hospitals. Kunstadter (1975) working in Northern Thailand, Leslie (1976)
in India, Janzen (1977) in the central Congo, Press (1969) in urban Colombia,
and many other medical ethnographers offer detailed documentation of this
marked pluralism of indigenous healing systems and of patients' pragmatic
orientation to available therapeutic resources.
In an epidemiologic study of the village of Kota in India, Carstairs and Kapur
(1976) identified three major types of traditional practitioners in addition to the
Western-trained physicians who served the population. The Vaids, practitioners
of Ayurveda, an indigenous system of empirical medicine with a vast pharma-
copeia, ascribe illness to an imbalance between the natural elements leading to
an excess of heat, cold, bile, wind or fluid secretions which can be caused by
such things as eating wrong food or uninhibited sexual indulgence; at the same
time, disease can be caused by pishachis or evil spirits; treatment is by herbs,
roots and pills. Mantarwadis are masters of the zodiac and of potent secret verses
termed mantras; cause is discovered through the zodiac and cure is carried out
through the mantra. The Patris act as mediums for a Bhuta or spirit which uses
the healer's body and voice as a means of communicating to the patient the ways
of exorcising evil. A survey of the populace revealed that although Western
practitioners were used as the sole source (40% of the time) more often than
indigenous healers only (14% of the time), the most common pattern of patient
care was to employ both Western and indigenous healers simultaneously (46%).
In a study in Taipei, Taiwan, Kleinman (1980) emphasizes the flourishing
side by side of Western-trained physicians; practitioners of classical Chinese
medicine; bone setters; pharmacists; fortune tellers; medicinal tea shops;
physiognomists; geomancers; ch'ien interpreters; herbalists; Taoist priests and
timg-kis (shamans); experts in massage; midwives; and still other folk practi-
tioners. Some are licensed; some are illegal; all seem to be in use. Each tradition
conceptualizes the hidden causes underlying the manifest illness in a different
but nonetheless narrow way. To illustrate the point, we need only compare
the practices of modern Western-trained physicians with those of the classical
Chinese physicians who still command a large clientele in Taiwan. Their medical
10 LEON EISENBERG AND ARTHUR KLEINMAN

behavior, no less than ours, is circumscribed by a set of theories which determine

the questions they ask in taking a history and the way they go about a physical
examination. In contrasting the patient encounters of Chinese-style with Western-
style physicians, Kleinman found that the mean time for the office transactions
was 7.5 minutes for the former as against 5 minutes for the latter, hardly an
impressive difference; moreover, both types of physicians limited their curiosity
to phenomena defined as relevant by their theories of disease; they afforded the
patient precious little time for discussion of personal concerns. As Kleinman
notes:

The popular medical ideology [in Taiwan] holds that the skills of the physician are demon-
strated by his ability to ascertain what is wrong from the pulse and perhaps from a few short
questions. The fewer the questions the better. A great doctor need ask nothing (1980:262).

The theories of the two types of practitioners could hardly be further apart; the
former utilizes almost no technology whereas the latter is heavily dependent
upon it. Yet the Chinese-style physician is no less remote than his Western
counterpart from the social and interpersonal dimensions of illness and health.
Recent outcome studies in Taiwan (A. Kleinman and J. L. Gale, unpublished
data) demonstrate that even those shamans, who may be on occasion strikingly
successful in responding to patients' personal troubles, do not systematically
recognize or attempt to relieve the psychosocial burden of illness (nor do they
practice without toxicity).
Thus, even the briefest epitome of traditional medicine in the developing
world makes evident its diversity and complexity; the term "traditional healer"
tells us almost nothing about a given practitioner without a detailed specification
of the culture and the locus in that culture within which he practices. The
celebration of the wisdom of the folk healer is part of the myth of a Golden
Age, when life was simpler and men healthier, a myth embedded in Western as
well as Eastern traditions. Edelstein (1967a, b) has contrasted the idea ofprog-
ress and the belief in an idyllic past during classical Greek antiquity. Dubos
(1959) quotes a Chinese scholar, Lieh-tzu of the fourth century B.C., who
depicted the Taoist vision of the ancient paradise on earth:

The people were gentle, following Nature without wrangling and strife ... Not till the age
of 100 did they die, and disease and premature death were unknown. Thus they lived ...
having no decay and old age ... (1959:9).

The readiness to believe in the fantasy of "primitive man" living in a Garden

of Eden accounts for the widely prevalent view of peasant society as somehow
more "organic" than our own, although Oscar Lewis (1951) long ago reported
how profoundly suspicion and envy permeate that world. Romanticism about
traditional healers obscures the far greater complexity of the reality of healing
practices. Healing ceremonies can be efficacious, but hardly substitute for anti-
biotics or surgery. Healers can be shrewd and insightful; but some are rigid
technicians who adhere (or are required to adhere) to a mechanical recitation of
 CLINICAL SOCIAL SCIENCE 11

ritual; and others are primarily concerned with personal gain. Few of the systems
of apprenticeship or formal training in traditional medicine include explicit atten-
tion to social and interpersonal considerations except in symbolic terms. Healers
are indeed taught the etiquette of medical behavior but often emphasis is on
impressing the client, rather than on understanding interpersonal interactions. In
precisely such terms the Hippocratic physician was exhorted to wear proper
garments, behave in a dignified fashion, refuse to treat hopeless cases lest he be
blamed, consider the impression his manner made on others, and so on (Edelstein
1967a :87 -110). In those instances when traditional healers modify standard
practice by taking into account the idiosyncracies of a given family within a
particular community, they rely on their tacit knowledge of village life rather
than on the formal doctrines of their sects, much as did the vanishing general
practitioners Peabody extolled.
Romanticism in anthropology and sociology leads to an overvaluation of the
skills of traditional healers; in consequence, it results in a reverse ethnocentrism
toward health care and the healing professions in our own society. In its most
grotesque form, we are presented with a caricature of the patient as a victim
and the physician as a jailer in Western medicine; whereas, the folk healer is
portrayed as an infmitely wise guru with an intuitive knowledge of sociology and
political science. This so distorts the real world as to turn clinicians away from
the cross-cultural literature in social science. The fact of the matter is that, while
traditional healing has many positive features, systematic understanding of the
psychosocial aspects of illness is largely a modern accomplishment based on
clinical and epidemiological studies of patients and healers in this and other
societies by social scientists and psychiatrists.
To recapitulate our argument, then, the deficits in the doctor's understanding
of the clinical encounter long ante cede the contemporary era; narrow specializa-
tion and high technology have further accentuated the dichotomy between the
patient's experience of illness and the doctor's concern with disease. The patient
who seeks yesteryear's nostalgic image of a family doctor in place of today's
biomedical expert would serve himself ill by foregoing remedies of proven value
in the search for illusory compassion. Doctors may rationalize an exclusively
biological focus by insisting on the priority of "facts" over "sentiments." Such
physicians were no less common 50 years ago or 500 years ago; they differed
only in what they consider to be "facts."
The key task for medicine is not to diminish the role of the biological sciences
in the theory and practice of medicine but to supplement it with an equal appli-
cation of the social sciences in order to provide both a more comprehensive
understanding of disease and better care of the patient. The problem is not "too
much science," but too narrow a view of the sciences relevant to medicine.
Why Social Science? Why Not More Biological Science?
The reader may object: Biomedical sciences have contributed greatly to
more effective medical practice. By definition, science is unfmished business;
12 LEON EISENBERG AND ARTHUR KLEINMAN

all answers are provisional. The one thing we can be certain of having is better
answers tomorrow than we have today. Why doubt that the remaining problems
of medicine will be solved by extending the very methods which have worked so
well to now? Why insist that modern biology is intrinsically incapable of provid-
ing a comprehensive account of sickness and a complete recipe for cure?
We reply: The factors that determine who is and who is not a patient can
only be understood by taking non-biological variables into account; patienthood
is a social state, rather than simply a biological one. Psychosocial variables
influence, not only the social and personal meanings of illness, but also the risk
of becoming ill, the nature of the response to illness and its prognosis.
The assertion that patienthood is a social condition may seem absurd. To
most physicians, patients are persons afflicted by disease ("real" patients) or
those who erroneously believe themselves to be so afflicted (the "worried well").
From this standpoint, getting well is a matter of being treated properly if one is
diseased or of being reassured accordingly if one is not. Since the central problem
is the presence or absence of disease, the only issues of interest to the doctor
are the agents, the mechanisms and the treatments of diseases.
Far from being self-evident, this disease-centered view completely overlooks
the complexity of the processes leading to the decision to see the doctor; that
i~, the decision to become a patient. Community surveys regularly identify many
more individuals with symptoms and many more with abnormal findings than
are under medical care at any given time (White et al. 1961; Mechanic and
Newton 1965), even in countries with comprehensive health care (Ingham and
Miller 1976). Every clinician is familiar with the patient whose disease has been
treated successfully but who obstinately persists in complaining of symptoms,
as well as the patient who drops out of treatment despite active disease.
The study by Peterson et al. (1977) of the treatment of peptic ulcer provides
a telling illustration. The investigators wished to study the effectiveness of high
dose antacid therapy for peptic ulcer. In order to provide as objective a measure
of outcome as possible, each patient was endoscoped at the beginning of the in-
vestigation and at the completion of the four week treatment period, after having
received active drug or placebo on a double blind protocol. The endoscopic
results were unequivocal: high dose antacid produced a much higher rate of ulcer
healing than did placebo (78% versus 45%). Yet, simultaneous assessment of
symptomatic change on antacid and placebo revealed no difference in clinical
outcome at the end of four weeks; symptom scores had been reduced to 20% of
the initial level in both groups. The discrepancy between ulcer healing rates and
symptom improvement rates makes it clear that some patients with healed ulcers
continued to have symptoms whereas others whose ulcer persisted had no com-
plaints of pain. As the authors comment: "Loss of ulcer symptoms did not
guarantee ulcer healing or even decrease in size." Other studies, which cannot
be reviewed in detail here, document the influence of culture on the complaint
pattern of patients with the same "objective" disease (Zola 1966), the signifi-
cance of the circumstances under which injury occurs for the amount of pain
 CLINICAL SOCIAL SCIENCE l3

the patient experiences (Beecher 1956) and the different criteria by which
patients and physicians judge the outcome of surgery (Cay et al. 1975).
To highlight these clinical phenomena, we propose to make a semantic dis-
tinction between "disease" and "illness," terms synonymous in contemporary
English usage. Physicians diagnose and treat diseases; that is, abnormalities in
the structure and function of body organs and systems. Patients suffer illnesses;
that is, experiences of disvalued changes in states of being and in social function
(Eisenberg 1977). Disease and illness do not stand in a one-to-one relationship.
Similar degrees of organ pathology can generate quite different reports of pain
and distress; illness may occur in the absence of detectable disease; the course
of the disease is distinct from the trajectory of the accompanying illness. A visit
to the doctor is more likely when disease is present, but it is essential to under-
stand that contracting a disease, feeling ill and being a patient are overlapping
but not co-extensive states.
En route to becoming a patient, the individual must make, almost always
with the advice of others, a self-diagnosis of being ill, a judgement made against
implicit standards of what it means to be well. Just as there is no completely
satisfactory medical definition of health, wellness means different things to
different people: feeling good, not having symptoms, being able to get the job
done, not believing oneself to be at risk or being told by the doctor that one is
well. Against this background of values which vary with social class and culture,
the process of decision-making is initiated by an experience of unexpected dis-
comfort, decrease in previous functional capacities and/or change in physicial
appearance.
A first decision must be made: is the change an important deviation or is it a
normal part of living? Can it be dismissed as transient? Is it to be attributed to
a recent event: something eaten, a muscle strain, the time of the month? Thresh-
holds for ascribed significance vary with life expectations; for the poor, pain
and fatigue may be part of life. Familiar symptoms are rarely frightening.
When ready or easily fabricated ways of explaining symptoms away are not
at hand, they suggest that there is something wrong. Among individuals under
stress, symptoms are not only more likely to occur but they are more likely to
lead to a search for help (Mechanic and Volkart 1961; Tessler et al. 1976).
Family members and friends are almost always consulted at this stage of evalua-
tion; they may be decisive in determining the actions taken (Twaddle 1977).
Once it has been decided that something must be done, the individual has to
identify the appropriate type of help: a family remedy, a folk healer, the local
druggist, a chiropracter, a physician, etc. The selection will reflect a judgement
about what is wrong and what type of treatment is needed, an expectation
which can lead to an impasse if the treatment prescribed by the practitioner
differs from the anticipated one.
Up to this point, a whole series of health care transactions has occurred out-
side the official medical network. Community studies indicate the some 75-90%
of episodes self-identified as illness are managed entirely without recourse to the
14 LEON EISENBERG AND ARTHUR KLEINMAN

health system (Hulka et al. 1972; Zola 1972). Yet, medicine has barely begun to
pay attention to the cumulative evidence that what doctors see in offices and
hospitals is a grossly unrepresentative sample of the illnesses and diseases which
occur in the community. Failure to appreciate the dimensions of the sampling
problem has consequences for disease diagnosis as well as for illness treatment.
The stubborn fact, the one that won't go away and that doesn't fit the
medical lexicon, is that what doctors choose to call "delay" is the rule in patient
behavior rather than an aberration. Severe trauma and overwhelming infection
aside, most patients appear in the office with symptoms which have been present
for weeks and months. Most people don't come in for most of their complaints
most of the time; that's normal illness behavior. Thus, it is a useless putdown to
ask a patient: "Why didn't you come in earlier?" when the meaningful question
is "Why did you come now?" The better we understand the triggers for deciding
to see the doctor, the better will we be able to respond to the patient's needs.
For example, Roghmann and Haggerty (1973), in a study of 512 young families,
asked each mother to keep a diary in which she recorded each day any upsetting
events which had occurred in the family. Analysis of the stressful events in rela-
tien both to illness episodes and to the use of medical care revealed different
effects on care patterns for the mother herself and for her children. The presence
of stress in the family and illness in the child increased the likelihood that medi-
cal care would be utilized for the child (from 1% to 15%). On the other hand, if
the mother was ill, family stress decreased the likelihood she would seek medical
care whereas it increased the likelihood she would see the doctor at times when
she was not ill. In a prepaid group practice, Tessler et al. (1976) found that
physician utilization increased in direct ratio to the amount of stress the patient
experienced; at the same level of health impairment, the individual under greater
stress was more likely to consult a physician. In the view of David Mechanic
(1978), the leading investigator in this area, the available evidence indicates that
distress has as powerful an effect on utilization behavior as does health status
itself.

HOW DOES THE MEDICAL CONSUMER VIEW SOCIAL SCIENCE?

However persuasive to us and to our readers the evidence that nonbiological

variables influence illness and care-seeking behavior and that social science
research therefore has high relevance to medical practice, the question remains:
what do doctors in practice think about applied social science? It is they who
will be the ultimate consumers of applied social science. The evidence is scanty.
Surveys of pediatricians in practice (Shonkoff et al. 1979) do indicate an aware-
ness of the inadequacy of conventional medical training for the behavioral
aspects of practice and a wish for more systematic instruction. Although research
reports and survey articles on social science are clearly under-represented in
medical journals, they have been considerably more frequent in the past decade
than they were earlier. The new programs in primary care and family practice,
 CLINICAL SOCIAL SCIENCE 15

and the journals devoted to these fields, both in England and in this country,
reflect growing sophistication in social science.
What is the attitude of medical educators, those who make the decisions on
whether the information the social scientist purveys will be included in formal
instruction to their students? That is what Professors Petersdorf and Feinstein
have endeavored to ascertain by a survey whose results are reported in the next
chapter of this book. They asked the Chairpersons of Departments of Medicine,
Pediatrics and Family Medicine their opinions of the current status of "medical
sociology," otherwise undefmed. On the basis of an unusually high response rate
to a mailed questionnaire, they provide a fascinating if disquieting snapshot of
current attitudes among the Professoriate.
They found, as expected, a "gradient of enthusiasm" with family medicine
most receptive, pediatrics less so and internal medicine the least. The gradient
from positive to negative parallels (a) the extent to which social scientists are
represented on departmental faculties in each area and (b) the amount of time
devoted to social science instruction during student clerkships and house officer
education. Whether familiarity leads to enthusiasm or enthusiasm to familiarity
cannot be said. What is evident from their responses is that even where the
attitude is the most favorable the time commitment remains quite limited and
the coverage spotty and unsystematic. Teaching and research in social science
continue to have relatively low priority in the allocation of departmental re-
sources.
If the utility of social science for clinical practice is to be judged from the
response to the Petersdorf-Feinstein questionnaire, the most optimistic conclu-
sion would be the Scot's verdict: not proven. The data also suggest another
conclusion: that medical educators, particularly those oriented to specialty
practice rather than primary care, reflect their prejudices rather than considered
judgements when they dismiss social science without much evidence of a serious
effort to familiarize themselves with its methods and findings. The topics in-
cluded by the respondents under the rubric of "medical sociology" reflect a
confusion of humanism, psychodynamics and medical ethics with social science;
the latter may have much to contribute to the clarification of each of these areas
Gust as it does to the identification of host factors in resistance to disease) but
it should not be equated with any of them any more than with biology. Helping
to make young doctors humane is more likely to be achieved by providing role
models of humane internists and pediatricians than by courses in literature or
philosophy. Humanism is a criterion by which all of us must be measured; we
are not convinced it is more often found among Professors of Romance Lan-
guages or American History than among Professors of Physics or Molecular
Biology.
Nonetheless, it would be a grievous error, in our estimation, to dismiss the
negative appraisal of those who collectively do much to determine the content
of medical education. The extent of their negative bias, at the least, serves to
define the size of the barrier to be overcome; more than that, it is likely to reflect