The modern legal definition of disease provides a useful starting point for an examination of the concept of disease and how it is regarded by various disciplines. According to Black's Law Dictionary (1990), disease is a "deviation from the healthy or normal condition of any of the functions or tissues of the body. An alternation in the state of the body or some of its organs, interrupting or disturbing the performance of the vital functions, and causing or threatening pain and weakness" (p. 467). To ensure that the concept is readily understood by legal practitioners, the editors add that disease is also called "illness, sickness, disorder, malady, bodily infirmity," and disease is, "An illness or an abnormal state having a definite pattern of symptoms" (Black's, 1990, p. 467). This comprehensive definition would also likely satisfy most lay observers today, but over time, the concept of disease has experienced some profound changes in the past two thousand years. The manner in which healthcare practitioners in ancient Greece diagnosed and treated disease influenced colonial America and this influence lingered well into the early nineteenth century wherein healthcare practitioners continued to rely on ancient methods to diagnose and treat their patients.
The basis for these changes was the concept of disease formulated by Hippocrates and Galen, based on a miasmatic concept of disease that involved an epidemic constitution of the atmosphere, corrupted by climatic, seasonal and astronomical influences (Baldwin, 1999). In his book, Pain and Profits, Mctavish (2004) reports that, "Most doctors in the nineteenth century were mainstream (that is, regular or orthodox) physicians who shared certain notions about health, disease, and treatment that stretched back to Galen and Hippocrates. They especially prided themselves on being 'scientific,' labeling all others as empirics -- or worse" (p. 16). According to Haller (1994), during this period in Western history, general medicine practitioners "reduced their medicine to a system based on first principles, from which all other propositions logically arose through deductive reasoning. Galen's system, for example, rested on the concepts of form and matter derived from Aristotle's metaphysics -- a deductive system similar in its logical rigor to geometry" (p. 17).
The concept of disease had not differed at this point in time in any substantive way from Galenic and medieval theory and regarded illness as being an anomaly in the "state" of the individual's constitution, with therapeutic measures directed at restoring balance through a variety of intrusive and potentially harmful regimens (Haller, 1994). At this time, the concept of disease was far more nebulous than today's more comprehensive definitions, and clinicians were stuck for explanations concerning what caused diseases and how best to treat them: "Instead of recognizing distinct diseases, doctors employed such catchall words as flux, fever, and dropsy to describe these perturbations" (Haller, 1994 p. 17).
While taxonomists had started the work that would serve to identify diseases by their symptoms and to differentiate particular, specific diseases, the underlying condition of disease continued to be viewed as a morbid state of the body's so-called "humors" that required "some form of bleeding, purging, sweating, or other restorative regimen" (Haller, 1994 p. 17). In this regard, Wells (1970) reports that, "The dominant doctrine of health and disease throughout the Middle Ages was the Humoral Theory, or Doctrine of the Four Elements. Its first complete enunciation, apparently, was by Pythagoras and through Aristotle, it exerted an immense influence on later thought" (p. 647). The work conducted by William Harvey, William Cowper, Thomas Willis, Felix Platter, James Yonge, and Thomas Sydenham represented the prevailing medical philosophy concerning the concept of disease at the end of the 17th century (Haller, 1994).
Thereafter, disease concepts were alternatively presented as causal networks that represent the relations among the symptoms, causes, and treatment of a disease and as the result of unseen pathogens; indeed, the shift to the germ theory of disease produced dramatic conceptual changes as the result of a radically new view of disease causation. For example, one authority notes that, "An analogy between disease and fermentation was important for two of the main developers of the germ theory of disease, Pasteur and Lister. Attention to the development of germ concepts shows the need for a referential account of conceptual change, to complement a representational account" (Van Loocke, 1999 p. 215).
Around the turn of the 20th century, Western views of the essential elements of medicine began to regard disease as.".. A phenomenon subject to natural laws, to be treated as we treat any other department of nature. The distinction between the attitude of the modern practitioner of medicine and the magico-religious attitude depends on the difference in the concept of disease in the two cases" (Smith, 1915, p. 4). During the 1950s, a configurationist approach began to place concepts of disease within the cultural contexts in which they occurred. According to Johnson and Sargent (1996), at this time, what counted were.".. not the forms but the place medicine occupies in the life of a tribe or people, the spirit which pervades its practice, the way in which it merges with other traits from different fields of experience. This was a harbinger of a radical shift from a historical approach to research on health phenomena to an ahistorical, empirical orientation. The emerging functionalism viewed society as comprising interrelated parts, concepts of disease and its causes, and the characteristic of healers being interdependent" (p. 114).
By the 1980s, disease was assumed by most mainstream healthcare practitioners to belong to the biomedical model and diseases were classified by only one set of (presumed) universally valid that were separated into such culture-independent categories (Keck, 1993). For example, according to Keck (1993), "In the 1980's the concept of disease is linked to the professional sector and its practitioners, who in the Western world belong to the biomedicine. The term illness, on the other hand, refers to the culturally defined perceptions and experiences of the patient and his/her social group" (p. 294). The mid-20th century was not exactly the precise demarcation point for this shift in concepts of disease by general medicine practitioners though. In fact, the need to take into account cultural contexts in formulating concepts of disease was made early on by Smith (1915), who emphasized, "It is evident that when we speak of the concept of disease held by such a people as the Melanesians we mean no exactly formulated definition, but a more or less vague system of ideas, which, though not distinctly formulated by a people, yet directs their behavior-their reactions towards those features of the environment which we have classified together under the category of disease" (p. 6). As Keck also emphasizes, "Judgments of suffering, being ill or well in an ethnic group are culturally defined, as they are closely connected to the view members of each culture take of life -- i.e. The way people perceive and structure their environment -- and to the characteristics of their social and religious system as well as their social values. There is also a connection to the concept of the person, including the dimensions of definition of the self" (p. 295).
The importance of these cultural aspects of the concept of disease has been borne out by a number of studies, including Frye (1991), who found that Cambodians immigrants are not assertive in seeking healthcare in since their arrival in America. "This lack of assertiveness has been attributed to high levels of depression, lack of English language abilities, and a cultural bias toward avoidance of confrontive situations," the authors note, and add, "Further, there is widespread misunderstanding among American health-care providers of Cambodian concepts of disease causation and traditional health modalities" (p. 36). These findings suggest that even the most advanced tertiary healthcare facility, replete with sophisticated (and expensive) diagnostic equipment and the best-trained general medicine practitioners may be missing something when it comes to the concept of disease in a multicultural society, and these issues are discussed further in Chapter 3 below.
General Medicine Concepts of Disease
Christopher Boorse criticizes the idea that health and disease are evaluative concepts. In his view, this relativizing of the concepts leads to absurd consequences. Assume, for instance, that one defines disease in terms of unwanted things which are candidates for medical treatment (Boorse, 1977). He claims that many recognized diseases are not really treatable. On the other hand, practices such as circumcision, termination of pregnancy or plastic surgery are not good reasons for considering the possession of foreskin, being pregnant or having ears that stick out to be diseases. Another possibility is that one invokes pain or suffering as a criterion for calling something a disease; however, Boorse emphasizes as well that medical textbooks frequently describe instances where the absence of subjective discomfort is accompanied by serious internal injury; by contrast, some people tend to experience severe pain and discomfort during entirely normal processes such as menstruation, teething and childbirth. In this regard, Boorse's theory attempts to show that health and disease are neutral concepts: "Disease and…