WHAT IS THE ESSENCE OF HEALTH AND DISEASE?

Björn SöderfeldtDepartment of Oral Public Health, Malmö University, SwedenFDI 2008

Starting point: Alfred Grotjahn

Who was Alfred Grotjahn?

1869 Born in Schladen am Harz1890 Accepted to medical education1912 Dozent Berlin university1919 Head of sanatoriums in Berlin1920 Professor of social hygiene, Berlin1921-24 Member of parliament for SPD1931 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 19123rd 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 orderExplanation in life historyPrognostic medicine

Disease as external entity (Paracelsus, Sydenham)Specific causes – specific treatmentExternal causesCurative medicine

Focus on biology

Classificatory nosology (Sauvage, Cullen)Causal or symptomalogic classificationsFocus on biological entities

Biological external entities (Bernard, Koch, Hirsch)Causes only biologicalAgent – host model - epidemiologyTwo agents – microbes and toxins

When biology fails:

Disease as psychological entities (Freud)Biological reflection of subconscious conflictsPsychological symbols

Disease as social entities (Parsons, Illich)Flight from social controlMedico-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:

Diagnosis1 Treatment1

Diagnosis2 Treatment2

Diagnosis3 Treatment3

Diagnosis4 Treatment4

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 PRACTICEWho should you treat treat ?

SOCIALLY ORIENTED PRACTICEHow to prevent ?

DISEASE ORIENTED PRACTICE

A given diagnosis does not give a specific treatmentIndividualization and differentiation in interaction between theory and practice

Diseases develop historicallyDiseases 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

GenderAgeTrainingPersonality

Care organizationWork loadControl over workFinancing system

Clinical judgment

HealthFearSelfesteem

Social classEducationResourcesEthnicity

GenderAgeExperiencePersonality

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 !!!