WHAT IS THE ESSENCE OF
HEALTH AND DISEASE?
Björn Söderfeldt
Department of Oral Public Health, Malmö University,
Sweden
FDI 2008
Starting point: Alfred Grotjahn
Who was Alfred Grotjahn?
1869 Born in Schladen am Harz
1890 Accepted to medical education
1912 Dozent Berlin university
1919 Head of sanatoriums in Berlin
1920 Professor of social hygiene, Berlin
1921-24 Member of parliament for SPD
1931 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 1912
3rd 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 order
Explanation in life history
Prognostic medicine
Disease as external entity (Paracelsus, Sydenham)
Specific causes – specific treatment
External causes
Curative medicine
Focus on biology
Classificatory 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
When biology fails:
Disease as psychological entities (Freud)
Biological reflection of subconscious conflicts
Psychological symbols
Disease as social entities (Parsons, Illich)
Flight from social control
Medico-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:
Theory
Diagnosis
Treatment
Practice
Diagnosis1
Treatment1
Diagnosis2
Treatment2
Diagnosis3
Treatment3
Diagnosis4
Treatment4
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 PRACTICE
Who should you treat treat ?
SOCIALLY ORIENTED PRACTICE
How to prevent ?
DISEASE ORIENTED PRACTICE
A given diagnosis does not give a specific
treatment
Individualization and differentiation in interaction
between theory and practice
Diseases develop historically
Diseases 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
Gender
Age
Training
Personality
Dentist
Care organization
Work load
Control over work
Financing system
Clinical
judgment
E
n
c
o
u
n
t
e
r
Gender
Age
Experience
Personality
Health
Fear
Selfesteem
Patient
Social class
Education
Resources
Ethnicity
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 !!!