Map of life expectancy at birth from Global Education Project.

Wednesday, January 26, 2005

Hold him in your arms, now you can feel his disease. . .

Probably not. In the glamorous, sexy, and highly lucrative field of medical sociology, we distinguish between disease and illness. (Don't go to your dictionary, this is jargon.) A disease is a label applied by a medical professional, signifying an abnormal and (in the labeler's opinion) undesirable, biological or psychological state or characteristic. In our society, the labelling (i.e., diagnosing) functionary usually holds the honorific of medical doctor and the the office of licensed physician. Also, the distinction between biology and psychology is eroding.

An illness is a set of undesirable sensations and/or limitations experienced by an individual, who attributes them to an abnormal biological or psychological state or characteristic. (Note that the idea of abnormality, in both cases, requires unpacking, but I won't do that now.)

In some cases, disease and illness are closely related and the two perspectives get along comfortably. The doctor tells you that you have osteoarthritis, and the main clinical manifestation is that your knees hurt. What bothers you is that your knees hurt, and you are very satisfied with that diagnosis. Of course, the meaning and consequences of aching knees vary tremendously from one person to another, so that every illness experience of arthritic knees is unique.

Sometimes, the disease and the illness don't get along well at all. The psychiatrist decides that the patient has borderline personality disorder, which he defines as an impaired ability to internalize objects and attributes to emotional neglect or abuse in infancy. The patient believes she is suffering because she has been betrayed and abandoned by a series of untrustworthy and fickle friends and lovers. These are radically different beliefs. Suppose the psychiatrist decided instead that the patient's problem was that she had the misfortune to have been betrayed and abandoned by a series of untrustworthy and fickle friends and lovers. The patient would still be suffering, but would not have a disease. (In practice, the psychiatrist would almost always find a disease label for her suffering, in this case perhaps an adjustment disorder, in order to get paid.)

Sometimes the disease label is the sole cause of the illness. For example, Cervantes was hop-scotching through life, whistling a happy tune, until his doctor told him he has hypertension and hypercholesteremia. Now he has to spend significant energy (and a bit of money) filling prescriptions, taking pills every day that sometimes make him dizzy, worrying about what he eats, etc. People who feel just fine are told that they are HIV positive, and all of a sudden they have an illness that is a major focus of their lives. They have to take numerous pills every day that likely make them sick and even cause bizarre changes in their body shapes; they often feel they must conceal their diagnosis from co-workers, friends, and family members; they worry about what to tell potential sexual partners, who may be repelled if they tell the truth; and so on.

Sometimes the illness is the sole cause of the disease. Doctors get very frustrated by people who come in with complexes of complaints that they can't explain biologically, so they ended up inventing disease labels for some of the most common ones -- fibromyalgia, Chronic Fatigue Syndrome. Some doctors object to these labels, others are searching for biological etiologies (causal stories) for them, and biological markers other than the patients' reported symptoms, which would confirm the "reality" of these diseases.

Sometimes, drug companies try to create disease labels. For example, they are making a lot of money selling various potions to give us guys those four-hour erections we keep hearing about during the time outs, but they are frustrated that they can only sell these to half the adult population. So they have been promoting a disease called Female Sexual Dysfunction, which basically means not having orgasms often enough to meet some arbitrary criterion, in hopes the disease will be generally accepted so they can sell pills to treat it. As Ray Moynihan writes in the British Medical Journal (January 21, 2005), "In the shadows of [the debacle over the non-existent "disease" of post-menopausal hormone deficiency], the pharmaceutical industry is meeting unexpected resistance to its attempts to sell women the next big profitable "disease," female sexual dysfunction. This condition is claimed by enthusiastic proponents to affect 43% of American women, yet widespread . . . disagreement exists over both its definition and its prevalence. "

This is all just a fancy way of saying that there is a fundamental difference in the perspectives of physicians and patients about the very nature of the basic subject matter of medicine. Does this ring true in light of your personal experience?

1 comment:

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This is what I like of this blog because I also can get information I didn't know for example the relation between illness and disease, because I thought it was completely the same, now I don't have any doubt about the difference.m10m