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Thursday, September 13th, 2007

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Physical Disorder as a Social Phenomenon

Friday, August 31st, 2007

Today I managed to pick up a copy of Roy Porter’s ‘The Greatest Benefit to Mankind: A Medical History of Humanity From Antiquity to the Present’. I’ve been intending to read his work for a while now as he is known as one of the best and most prolific, historians of medicine.

One thing that I’ve been thinking on is how psychiatric disorders might be partly due to sociological factors. This is something that anti-psychiatrists have been suggesting for a while now and social factors certainly seem to make the best sense of some of the questions we can ask (e.g., ‘why are eating disorders more prevalent in developed western nations?’ )

He begins with an account of how early humans didn’t suffer much from disease (though would have suffered from injury) as groups were too small for diseases to thrive in. Our social structure began to change, however. People started congregating in one place and the rise of agriculture brought with it contaminated water supplies, and increased contact with disease carrying animals such as cows, chickens, and rats.

‘There may have been a similar trade-off respecting the impact of the Industrial Revolution, first in Europe, then globally. While facilitating population growth and greater (if unequally distributed) prosperity, industrialisation spread insanitary living conditions, workplace illnesses and ‘new diseases’ like rickets. And even prosperity has had its price, as Cheyne suggested. Cancer, obesity, gallstones, coronary heart disease, hypertension, diabetes, emphysema, Alzheimer’s disease and many other chronic and degenerative conditions have grown rapidly among today’s wealthy nations. More are of course now living long enough to develop these conditions, but new lifestyles also play their part…

And all the time ‘new’ diseases still make their appearance, either as evolutionary mutations or as ‘old’ diseases flushed out of their local environments (their very own Pandora’s box) and loosed upon the wider world as a result of environmental disturbance and aconomic change. The spread of AIDS, Ebola, Lassa and Marburg fevers may all be the result of the impact of the West on the ‘developing’ world – legacies of colonialism. Not long ago medicine’s triumph over disease was taken for granted…

The systematic impoverishment of much of the Third World, the disruption following the collapse of communism, and the rebirth of an underclass in the First World resulting from the free-market economic policies dominant since the 1980’s, have all assisted the resurgence of disease. In March 1997 the chairman of the British Medical Association warned that Britain was slipping back into the nineteenth century in terms of public health. Despite dazzling medical advances, world health prospects at the close of the twentieth century seem much gloomier than half a century ago. The symbiosis of disease with society, the dialectic of challenge and adaptation, success and failure, sets the scene for the following discussion of medicine (p.29-30)’

‘Medicine has become the prisoner of its success. Having conquered many grave diseases and provided relief from suffering, its mandate has become muddled. What are its aims? Where is it to stop? Is its prime duty to keep people alive as long as possible, willy-nilly, whatever the circumstances? Is its charge to make people lead healthy lives? Or is it but a service industry, on tap to fulfil whatever fantasies its clients may frame for their bodies, be they cosmetic surgery and designer bodies or the longing of post-menopausal women to have babies? …

Who can decide the direction medicine should now take? In the rich world, it has accomplished its basic targets as understood by Hippocrates, William Harvey or Lord Horder – who will decide its new missions? The irony is that the healthier western society becomes, the more medicine it craves – indeed, it regards maximum access as a right and duty. Especially in free market America, immense pressures are created – by the medical profession, by medi-business, the media, by the high pressure advertising of pharmaceutical companies, and dutiful (or susceptible) individuals – to expand the diagnosis of treatable illnesses. Scares are created. People are bamboozled into lab tests, often of dubious reliability.

Thanks to diagnostic creep or leap, ever more disorders are revealed. Extensive and expensive treatments are then urged, and the physician who chooses not to treat may expose himself to malpractice accusations. Anxieties and interventions spiral upwards like a space-shot off course. The root of the trouble is structural. It is endemic to a system in which an expanding medical establishment, faced with a healthier population, is driven to medicalising normal events like menopause, converting risks into diseases, and treating trivial complaints with fancy procedures (p.717-718).’

The more I look into the history and philosophy of medicine the more I find that the features that the anti-psychiatrists have considered most problematic about psychiatry are also to be found as problematic in general medicine. The distinction between ‘mental’ (psychiatric) and ‘non-mental’ (e.g., neurological) disorder is problematic, but drawing hard and fast lines between medical specialities can seem similarly problematic (unless, of course, one is a dualist about the mind). Social factors seem to be important to both psychiatry and to general medicine and social factors seem to be similarly underappreciated in each. The distinction between health and illness and problems in living seems similarly controversial in cases where our values diverge.
Psychiatry: Once concerned with severe cases of psychosis where people were severely functionally impaired and needed to be institutionalised or otherwise in custodial care. Medicine: Once concerned with severe cases of pathogen or structural trauma where people were severely functionally impaired and even close to death.

Over time both fields have broadened the class of phenomena that falls under the scope. While past medical practices are often critiqued by being tied up with spiritual notions of demons and prayers is the present system any better for being tied up with business interests in pharmaceuticals? Porter asks us where medicine is headed. What is the point? This is a question that psychiatry also needs to be asking itself but it is somewhat reassuring that it isn’t simply a problem for psychiatry. The same seems to be true of general medicine as well.