WHAT IS THE ESSENCE OF HEALTH AND DISEASE? Björn Söderfeldt Department of Oral Public Health, Malmö University, Sweden FDI 2008
Starting point: Alfred Grotjahn
Who was Alfred Grotjahn? 1869 Born in Schladen am Harz 1890 Accepted to medical education 1912 Dozent Berlin university 1919 Head of sanatoriums in Berlin 1920 Professor of social hygiene, Berlin 1921-24 Member of parliament for SPD 1931 Deceased “The father of social medicine”
Main work: SOZIALE PATHOLOGIE - Versuch einer Lehre von den sozialen Beziehungen der Krankheiten als Grundlagen der sozialen Hygiene. Berlin, Hirschwald Verlag 1st edition 1912 3rd edition 1923 facsimile edition 1977
Four principles of Soziale Pathologie 1. The social importance of sicknesses follow from prevalence. Social pathology is NOT clinical pathology! 2. Pathology is necessary but not sufficient to understand sickness. Social causes affect predisposion for disease, carry its contingencies and affect its course in interaction with biology. 3. Sickness affects social conditions. Two processes with equal result: “minderwertige Schwächlinge” - inferior weaklings 4. Medical treatment should be evaluated socially. The eugenic dilemma – successful cure gives survival of sickness predispositions!
Some applications: Smallpox : A ”dirt disease”. Quarantine and not inoculation the effective measure. Thus a question of quality and efficiency of the state. Tuberculosis : Predisposition due to physical inferiority. Cure not desirable since predispositions survive – the eugenic dilemma. Asylums with celibacy – sanatoriums –only effective measure. The goal was not cure but avoidance of procreation!
Basedow’s disease : Unknown cause, but probably inherited nervous disease. Primarily in women with anemia and weak chest. Should be expelled from procreation in asylums and forced abortions! Psychopathy : Inherited disposition of both criminals and geniuses. The eugenic dilemma again, but the problem is to distinguish the good from the bad. Solution: Sorting in school by doctors!
Why these ideas? Grotjahn reflects his time, but also exemplifies ESSENTIALISM, the thought that sickness – or phenomena at large – in reality are something else than what they appear In Grotjahn’s case, the essence is heredity, but there are many variants (Juul Jensen 1985):
Different disease concepts – different essences Disease as lack of balance (Antiquity) Natural or heavenly order Explanation in life history Prognostic medicine Disease as external entity (Paracelsus, Sydenham) Specific causes – specific treatment External causes Curative medicine
Focus on biology Classificatory nosology (Sauvage, Cullen) Causal or symptomalogic classifications Focus on biological entities Biological external entities (Bernard, Koch, Hirsch) Causes only biological Agent – host model - epidemiology Two agents – microbes and toxins
When biology fails: Disease as psychological entities (Freud) Biological reflection of subconscious conflicts Psychological symbols Disease as social entities (Parsons, Illich) Flight from social control Medico-industrial complex conspiracy Disease as social construction (Foucault) Socially useful classification of humans Disease as statistical extreme (Boorse) Deviation from typical development Disease as equilibrium (Pörn, Whitbeck) Balance between vital goals and abilities
What is the basic structure of all this and what has it to do with odontology?
A paradigmatic crisis of medicine!
Medicine (and odontology) is the practice of the clinical collective and relies on two basic principles: 1. ESSENTIALISM – there are ’real’ diseases and a natural limit between healthy and sick 2. SPECIFIC TREATMENT – there is a specific treatment for diseases The crisis is constituted by the dissonance between these principles and the actual situation:
Diagnosis 1 Treatment 1
Diagnosis 2 Treatment 2
Diagnosis 3 Treatment 3
Diagnosis 4 Treatment 4
Diagnosis Treatment Theory Practice
An essentialist concept of disease is impossible and untenable There is nothing which diseases ”actually” are Diseases are delimited in practice, not in theory Medical and odontological science must start in clinical practice, not conversely Diseases are historical phenomena, changing dynamically
THREE TYPES OF PRACTICE DISEASE ORIENTED PRACTICE How to treat ? SITUATION ORIENTED PRACTICE Who should you treat treat ? SOCIALLY ORIENTED PRACTICE How to prevent ?
DISEASE ORIENTED PRACTICE A given diagnosis does not give a specific treatment Individualization and differentiation in interaction between theory and practice Diseases develop historically Diseases begin in historical exemplars (Kuhn) Syndromes become diseases Complex social processes decide which syndromes that become diseases, and which not
Factors in the establishment of diseases Provenience and legimacy in the medical profession – biological indicators? (e.g. burnout) Legal recognition – dependent on the profession ? (e.g. forensic psychiatry) Ability of social mobilization ? (e.g. oral galvanism) Social functionality in labeling deviants ? (e.g. DAMP, MBD)
Therapy is not the application of basic science Clinical medicine and odontology are not applied human biology Clinical practice governs, and should govern, theory The end of Flexnerian medicine!
The main effect of biological essentialism is to limit the development of treatment instruments! You search where you think you can find something. Clinical practice should use ALL knowledge in the interplay between practice and theory, i.e. also behavioral and social instruments
SITUATION ORIENTED PRACTICE A practice for holistic evaluation of the patient Subject-subject relation Evaluation of malconditions in the life situation of the patient in relation to available actions
Developing methods for dialogue, interpretation and empowerment Interpretation of latent needs Emancipatory action discovering new needs Understanding of the complexity of THE CLINICAL ENCOUNTER
The clinical encounter Dentist Patient Encounter Gender Age Training Personality Care organization Work load Control over work Financing system Clinical judgment Health Fear Selfesteem Social class Education Resources Ethnicity Gender Age Experience Personality
A salutogenetic health concept! Health is a process and not a state The self-efficiacy, i. e. empowerment, of the patient is the strategic goal
Bewitched by the precision and standardization of laboratory technology, clinicians have abandoned or failed to improve the precsion and standardization of their own observations and reasoning, and rejected their sensory and cerebral capacities as inherent defects, flaws and scientifically undesirable elements that have to be avoided or replaced by dead technology. (Alvan Feinstein, “Clinical Judgment” 1967)
SOCIALLY ORIENTED PRACTICE – the area of public health Interaction between social forces
Disease is not evil Nature but socially contingent In professionalization and Taylorist fragmentation of work, the holistic perspective is lost. Rationality becomes instrumental to discover means to affect Nature, not human beings Epidemiology: Disease is caused by external natural agents. Ideology of public health
The power of ideology, or the ideology of power Power is to prevent people from having grievances by forming them in such a way that they accept their role in the existing order, either because they cannot see or imagine any alternative, or because they see it as natural or heavenly ordained (Steven Lukes ”Power – a radical view” 1991)
Society is neither the state nor the market ”Kolonisierung der Lebenswelt”, either by the state: Love in office hours, or by the market: Love as a commodity The alternative: Restoration of the Life World!
Instead of the EU, Swedish author Torbjörn Säfve suggested the Sufic Love Emirate: Good food, real clothes, fresh nature, blooming love, and free art That is Health !!!