LECTURE 2

1. LECTURE 2 THE HISTORY OF DISEASE

2. Overview. • History of disease • epochs of disease • cross cultural and trans-historical theories of disease • social constructionist arguments. • classifying medical systems • historical trajectory of the treatment of disease.

3. The epochs of Disease. 1 • Broadly 3 periods -characterized by different ways of life and different disease problems. 1. Pre-agricultural society- • Before organized argriculture, hunter gatherer societies, Life short but healthy, adult mortality linked to search for food supplies, few infectious diseases. population growth restricted by high mortality. Life was short but comparatively healthy (McKeown)

4. The epochs of Disease. 2 2. Agricultural Societies- Sedentary man; cultivation of crops ; domestication of animals. increasing numbers of people together living together; poor hygiene; insufficient food. • Growth of large settled communities. Some advantages but costs outweigh benefits. • Encourages spread of many diseases as opened up more to trade and communication. • Also because build and live in more settled houses –encourages disease transmission – attract vermin – rodents and mosquitoes. Eg influenza –disease of civilization. • Refuse attracts wild animals – this is the means through which rat borne bubonic plague is brought into human communities • Rise in instances of fecal-oral transmission –worms; dysentery etc • Insect borne disease • Domestication of animals and disease • Increased population density- important factor in the spread of disease.

5. four key factors in the spread and increase in disease So we have four key factors in the spread and increase in disease . 1 Increased communication 2sendentarism 3. domestication of animals 4. population density

6. Globalisation of Disease. • William Mc Neil - 3 major events of transportation: • Linking of China, India and Mediterranean by sea and land in Christian era • Spread of European seaborne exploration in 15th century (brought bubonic plague to Europe) • Mongol expansion to Europe

7. The epochs of Disease. 3 3. Modern Industrial societies- decline in mortality from infectious diseases; little to do with modern medicine according to McKeown. Rise in ‘Modern diseases’ cancers, heart disease and strokes, diabetes etc • Modern illness non-communicable, chronic (longlasting) and progressive. • a number of risk factors • linked to lifestyle. • avoidable but not ‘curable’ • increasingly aging population • changes in conditions of life and industrialization. • Diseases of developing world.

8. The Classification of Medical Systems 1 Dunn. • Distinguishes between systems according to the geographical extent of their influence. • Local Medical Systems- Those confined to a small geographical area. • eg. The !Kung of the Kalahari desert. • Regional medical Systems- Those that have wider geographical influence, perhaps across an entire continent. • eg. Ayurvedic Medicine found throughout the Indian subcontinent. • Cosmopolitan Medical Systems- Those that are exported and adopted worldwide. • eg. Western medicine (bio-medicine) and homeopathy.

9. The Classification of Medical Systems 2 Foster. • Focuses on the nature of belief systems and how they influence medical discourse. Distinguishes between:- • Personalistic Systems-Those that interpret sickness supernaturally. In these systems sickness is viewed as punishment by a supernatural being or by an individual practising magic or witchcraft. In these systems preists or shamans are required to alleviate or cure symptoms. • Voodoo in Haiti. • Naturalistic Systems-Those that explain health and ill-health in terms of a balance or imbalance in the basic elements of the body, often called equilibrium theories. In these systems physicians or herbalists with expert knowledge are required to restore health and the bodies natural balance. • eg. Plato's 3 state model. Hippocrates' 'Four Humours. Chinese Medicine 'Yin, Yang'.

10. The Classification of Medical Systems 3 Leslie • Distinguishes between: • Mechanistic theories. - human body seen as machine-like, illness a dysfunction or breakdown. • eg. Western Medicine. • Equilibrium theories- (Similar to Foster's 'Naturalistic Systems') illness a result of disequilibrium or disharmony in the body. Health a result of harmony or balance • eg. Chinese medicine. • Ethical theories- health is a result of 'right living' illness is a punishment for sin or wrong-doing. • eg. Magico-religious systems. Ndembu in Zambia.

11. The development of scientific medicine EARLY HUMANS: (before 3000 B.C.) • Supernatural Belief Systems: magico-religious or supernatural explanations of disease. • Causes of disease: by direct intervention of a god or spirit, or through a sorcerer or through the intrusion of some foreign object (spirit or demon or something more tangible such as a stone or pebble) into the body. • Cures: religious rituals (prayer, magic spells, exorcism, dancing, sacrifices) or physical means (sucking out, vomiting, bloodletting, skull trepanation) • The first physicians were known as the shaman (or the witch doctor or medicine man).

12. The development of scientific medicine -THE EGYPTIAN CIVILIZATION (3000 B.C.) • Egyptian physicians were specialists and religious leaders. Each was devoted to a different god. Diseases were associated with their deity. • Egyptian medicine produced two noteworthy documents: the Code of Hammurabi which is possibly the first codified set of guidelines regarding responsibilities of physicians, and the Ebers Papyrus, a type of medical textbook summarizing extant medical knowledge.

13. The development of scientific medicine -GREEK AND ROMAN SOCIETIES: (2000 B.C.) 1 • Apollo, the sun god, was also god of health and medicine. • Aesculapius, son of Apollo, was the Greek god of health. • Temples called "asklepieia" were created where priest-physicians could practice. • Hippocrates: The Father of Medicine. (460-377 B.C.) • The principle of natural, rather than supernatural, explanations for disease - humoral theory of disease: linked to the body in the natural environment- early materialist notions. The natural elements such as air, earth, fire, and water balance with the element in the body such as blood (hot), phlegm (cold), yellow bile (dry), and black bile (wet). A person is healthy when these four humors are in balance and when the individual is in balance with the environment. • His writing - over 70 books, monographs, and essays - focusing on the importance of observing disease progression and described his own copious note taking of medical histories, symptoms, and reactions to therapy when treating patients, also the notion of treating the "whole patient," not just a particular organ or symptom.

14. The development of scientific medicine -GREEK AND ROMAN SOCIETIES: (2000 B.C.) 2 • His teaching of human compassion and ethical standards - Hippocratic Oath. • Asclepiades (a Greek physician) • Causes of disease: health and illness were determined by the condition of the pores - either too open or too closed. • Cure: massage, diet (wine) and baths. • Roman households ministered to the sick in their own families. They did not produce their own physicians in the beginning. • Roman contributions to medicine: public health (pure water, public baths, street cleanliness, and hospitals). Direct link made here between hygiene and health.

15. The development of scientific medicine -THE MEDIEVAL ERA: (A.D. 500-1500) • Monastic Medicine: church controlled the medical practice Disease and illness are beneficial in that they test one's faith and commitment to God and the church. Despite this the earliest hospitals developed in the monastic period. • Causes of disease: due to the punishment by God, possession by the devil, or the result of witchcraft. • Private physicians represented a form of blasphemy in their efforts to cure disease, no cure apart from religious intervention. Preist responsible for this. • Arabic Medicine: Contrast- built hospitals and bestowed high prestige on private physicians, and basically served as the link between Greek medicine and Renaissance medicine. • Scholastic Medicine: medicine practice became the province of the secular clergy, and universities began to plan a prominent role in the education of physicians. • Two other occurrences during the period: there were numerous devastating epidemics (e.g., Black Death) that made clear the total helplessness of physicians to restrain disease.

16. The development of scientific medicine -MEDICINE IN THE RENAISSANCE: (15C - 16C) • Focuses on humanism: dignity of the individual, the importance of this life, and spiritual freedom. • Andreas Vesalius and Paracelsus both attacked Galen's anatomy. • Medical specialization: physicians, surgeons, barber surgeons and apothecaries.

17. The development of scientific medicine -MEDICINE FROM 1600 TO 1900: • Focusing on science, observation, and experimentation. • William Harvey's confirmation of the circulation of blood in the 17C body comes to be viewed as a machine. • In the 17C, scientific medicines were met with skepticism, medicine superstitions were still common, some physicians focused on the physician-patient relationship and on the body's self-healing capacity, and in this way, maintained the Hippocratic tradition. • In the 18C: Development of a modern concept of pathology: Giovanni Battista Morgagni's anatomical concept of disease - diseases could be traced to a particular pathology or disturbance in individual organs. • The emergence of public health (sanitary conditions and water supplies) and preventive medicine (using cowpox vaccine to prevent smallpox by Edward Jenner).

18. The development of scientific medicine -19C: industrialization, migration and urbanization: • The emergence of Hospital medicine and laboratory medicine. • Early part of century a diversity of beliefs many still believe disease caused by Miasma- airborne poisonous gas from sewers and cesspits which infects wounds or lungs. Later part of century diversity of belief contained by growing development of a scientific bio-medical model resting on a number of major developments (influence of Cartesianism, mechanism, duality) more about this week after next. • Discovery of the cell by Rudolf Virchow: disease begins with some alteration in the normally functioning, healthy cell. Effective treatment depends on restoring the cell to normality. He also emphasized on the importance of environmental influences (social class, occupation, social networks) on health and illness, and referred to medicine as a "social science" and as the "science of man". (Virchow).

19. Germ Theory and the Doctrine of Specific Aetiology • The germ theory of disease by Louis Pasteur in 1850’s (the Father of Modern Medicine) I will discuss this in more detail the week after next. • 1880’s Robert Koch elaborates Pasteurs germ theory- into ‘Doctrine of specifc aetiology’ each disease caused by particular micro organism. • Progress in surgery: an understanding of the localized nature of disease, an ability to control patient's pain in the surgical process, and an ability to prevent wound infection.

20. The Role of Medicine in the decline of disease. Food and Agriculture. • Perhaps improvements medicine not as central as you might think (Mc Keown). • Improvements to agriculture around 17th century • important in improving diet. • New crops • new agricultural techniques • Better nutrition - greater immunity • relationship between levels of immunity and poverty

21. The Role of Medicine in the decline of disease. Hygiene and drinking water. • From mid 19th century improvements in hygiene • purification of water and sewage disposal. • From 1900 improvement in quality of milk was very important • New sterilization techniques (Does this contradict Mc Keown?)

22. The Role of Medicine in the decline of disease. Birth Rates. • decline in the birth rate. • Sex education and contraception • (McKeown) - pre-modern society (and contemporary developing societies) out of new born children, on average, 23% died before their first birthday, 56% (Check these figures) by age 6 • In technologically advanced society more than 95% survive to adult life. • Average life expectancy in Sierra Leone currently 34. • Infant death rates fell dramatically from mid 19th century • (Mc Keown) - since the mid 19th century, 40% decline in mortality from airborne diseases, 21% decline from water and food borne diseases, 13% from other infections, and the remainder (26%) from non-infective conditions.

23. Conclusion. • Different periods characterized by different material conditions. • Different material conditions give rise to different kinds of disease. • Disease interpreted differently in different contexts. • Does this mean health, illness and disease are cultural constructs? • Mc Keown contradicts ‘common sense assumptions about role of medicine in decline of disease.

24. Next week • The development of modern medicine and the hospital; • public health, the bureaucratization, rationalization and ‘technologization’ of medicine and health care. • Home work- read the hand out on Weberian models of Bureaucratization and see how we might apply this to health care.