Starting point: Alfred Grotjahn

1. WHAT IS THE ESSENCE OF HEALTH AND DISEASE?Björn SöderfeldtDepartment of Oral Public Health, Malmö University, SwedenFDI 2008

2. Starting point: Alfred Grotjahn

3. 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”

4. 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 1923facsimile edition 1977

5. Four principles of Soziale Pathologie1. 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 weaklings4. Medical treatment should be evaluated socially. The eugenic dilemma – successful cure gives survival of sickness predispositions!

6. 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!

7. 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!

8. 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 appearIn Grotjahn’s case, the essence is heredity, but there are many variants (Juul Jensen 1985):

9. Different disease concepts – different essencesDisease as lack of balance (Antiquity) Natural or heavenly order Explanation in life history Prognostic medicineDisease as external entity (Paracelsus, Sydenham) Specific causes – specific treatment External causes Curative medicine

10. Focus on biologyClassificatory 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

11. When biology fails:Disease as psychological entities (Freud) Biological reflection of subconscious conflicts Psychological symbolsDisease as social entities (Parsons, Illich) Flight from social control Medico-industrial complex conspiracyDisease 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

12. What is the basic structure of all this and what has it to do with odontology?

13. A paradigmatic crisis of medicine!

14. 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 sick2. SPECIFIC TREATMENT – there is a specific treatment for diseasesThe crisis is constituted by the dissonance between these principles and the actual situation:

15. Theory Diagnosis Treatment Diagnosis1 Treatment1 Diagnosis2 Treatment2 Diagnosis3 Treatment3 Diagnosis4 Treatment4 Practice

16. An essentialist concept of disease is impossible and untenable There is nothing which diseases ”actually” areDiseases are delimited in practice, not in theory Medical and odontological science must start in clinical practice, not conversely Diseases are historical phenomena, changing dynamically

17. THREE TYPES OF PRACTICEDISEASE ORIENTED PRACTICE How to treat ? SITUATION ORIENTED PRACTICEWho should you treat treat ?SOCIALLY ORIENTED PRACTICEHow to prevent ?

18. DISEASE ORIENTED PRACTICEA given diagnosis does not give a specific treatmentIndividualization and differentiation in interaction between theory and practiceDiseases develop historicallyDiseases begin in historical exemplars (Kuhn)Syndromes become diseasesComplex social processes decide which syndromes that become diseases, and which not

19. Factors in the establishment of diseasesProvenience 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)

20. Therapy is not the application of basic scienceClinical medicine and odontology are not applied human biologyClinical practice governs, and should govern, theoryThe end of Flexnerian medicine!

21. 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

22. SITUATION ORIENTED PRACTICEA practice for holistic evaluation of the patientSubject-subject relationEvaluation of malconditions in the life situation of the patient in relation to available actions

23. Developing methods for dialogue, interpretation and empowermentInterpretation of latent needsEmancipatory action discovering new needsUnderstanding of the complexity of THE CLINICAL ENCOUNTER

24. The clinical encounter Gender Age Training Personality Gender Age Experience Personality Encounter Clinical judgment Health Fear Selfesteem Dentist Patient Care organization Work load Control over work Financing system Social class Education Resources Ethnicity

25. A salutogenetic health concept!Health is a process and not a stateThe self-efficiacy, i. e. empowerment, of the patient is the strategic goal

26. Bewitched by the precision and standardization oflaboratory 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)

27. SOCIALLY ORIENTED PRACTICE – the area of public healthInteraction between social forces

28. Disease is not evil Nature but socially contingentIn 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

29. The power of ideology, or the ideology of powerPower 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)

30. 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!

31. Instead of the EU, Swedish author Torbjörn Säfve suggested the Sufic Love Emirate:Good food, real clothes, fresh nature, blooming love, and free artThat is Health !!!