Situational disease: elements of a social theory of disease based on a study of back trouble.

Abstract

According to the British general practitioner and anthropologis t Cecil Helman the biomedical model of disease can be characterized by body – mind dualism, scientiŽ c reductionism, and a predominant emphasis on biologica l rather than social-psycho logical information (1). This model is detailed out in biomedical everyday practice, where diseases are often conceived of as separate entities that can be fully described by way of a diagnosis – encompassing a name, pathology, etiology, prognosis , etc. In clinical work, this diagnostic description is considered objective knowledge with global validity (2). However, medical philosophers and metascientists in general do not subscribe to this view, and several medical disciplines (e.g. social medicine, general medicine, psychiatry) are only in part devoted to the biomedical model (3). Today, there is an increasing amount of medical theoretical work underway which offers new perspectives on the nature of disease. The biomedical model is no longer dominant in the theoretical discourse the way it still is in practice. In psychosomatics and in stress theory, in anthropolog y and sociology we are confronted with new ideas and new conceptualiza tions of disease, for instance the holistic model and the patient-centred model. What these concepts have in common is context – meaning that disease is inextricably bound up with time, with a person, with situations and with biography . This article presents one such contextual contribution to the ongoing theoretical discussion on the nature of disease. Here, the perspective of disease as a social and relational phenomenon – a phenomenon developed and shaped through the interaction of people in a social everyday world – emerges on the basis of an empirical study of the prevalence and handling of back troubles in a general adult population. The data are subsequently interpreted in the light of sociologica l theory. THEORETICAL BACKGROUND Around 1980, the American sociologis t Angelo Alonzo developed a model of illness behaviour which he labelled ‘‘a situational perspective’’ (4,5). This work will be brie y described. A premise of Alonzo’s theory is that bodily deviations – like symptoms and physical signs – are experiences that are typical of our everyday life. While we constantly interact with our environment and experience ourselves accordingly , we perceive a multitude of bodily sensations that must be interpreted, evaluated and eventually acted upon. Each person is involved in and goes through a number of daily social situations which demand some involve ment, and often some activity, from him. Normally, there is a certain repetitive pattern in the set of situations in which we involve ourselves day after day, week after week. A key issue is that of ‘containment’. In the  ow of bodily symptoms and sensations, the question arises: can these be contained within the situation so that the individual can preserve his core activity (e.g. working) in the situation? For example, can the pain in the back or the itching of the hands be concealed, suppressed or attended to in such a way that working may go on undisturbed? If the symptoms cannot be thus contained within the situation, the person may have to leave the situation intermittently or permanently. Thus, situations can be thought of and analysed, not just in terms of their potential to produce signs or symptoms either during or after participation , but in terms of their capacity to contain symptoms as well. In Alonzo’s theory of situational behaviour , disease is thus not conceptualized as something going on within the body (though it may well be, only this theory is not concerned with it), but rather something which happens and is handled through a person’s experience of elementary sensations and actions in a series of situations. The kind of symptoms Alonzo refers to are, for example, cough, cold,  u, ache, stiffness, swelling,