WHAT IS THE ESSENCE OF HEALTH AND DISEASE? Bj

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WHAT IS THE ESSENCE OF HEALTH AND
DISEASE?Björn SöderfeldtDepartment of Oral
Public Health, Malmö University, SwedenFDI 2008
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Starting point Alfred Grotjahn
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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
DeceasedThe father of social medicine
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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
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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!
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Some applicationsSmallpox 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!
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Basedows 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!
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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
Grotjahns case, the essence is heredity, but
there are many variants (Juul Jensen 1985)
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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
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Focus on biologyClassificatory nosology
(Sauvage, Cullen) Causal or symptomalogic classif
ications Focus on biological entities
Biological external entities (Bernard, Koch,
Hirsch) Causes only biological Agent host
model - epidemiology Two agents microbes and
toxins
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When biology failsDisease as psychological
entities (Freud) Biological reflection of
subconscious conflicts Psychological
symbolsDisease as social entities (Parsons,
Illich) Flight from social control Medico-indust
rial 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
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What is the basic structure of all this and what
has it to do with odontology?
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A paradigmatic crisis of medicine!
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Medicine (and odontology) is the practice of the
clinical collective and relies on two basic
principles1.ESSENTIALISM there are real
diseases and a natural limit between healthy and
sick2. SPECIFIC TREATMENT there is a specific
treatment for diseases The crisis is
constituted by the dissonance between these
principles and the actual situation
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Theory
Diagnosis Treatment
Practice

• Diagnosis1 Treatment1
• Diagnosis2 Treatment2
• Diagnosis3 Treatment3
• Diagnosis4 Treatment4

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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
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THREE TYPES OF PRACTICEDISEASE ORIENTED
PRACTICE How to treat ? SITUATION ORIENTED
PRACTICEWho should you treat treat ?SOCIALLY
ORIENTED PRACTICEHow to prevent ?
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DISEASE ORIENTED PRACTICEA given diagnosis does
not give a specific treatmentIndividualization
and differentiation in interaction between theory
and practiceDiseases develop historicallyDiseas
es begin in historical exemplars (Kuhn)Syndromes
become diseasesComplex social processes decide
which syndromes that become diseases, and which
not
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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)
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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!
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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
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SITUATION ORIENTED PRACTICEA practice for
holistic evaluation of the patientSubject-subjec
t relationEvaluation of malconditions in the
life situation of the patient in relation to
available actions
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Developing methods for dialogue, interpretation
and empowermentInterpretation of latent
needsEmancipatory action discovering new
needsUnderstanding of the complexity of THE
CLINICAL ENCOUNTER
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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
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A salutogenetic health concept!Health is a
process and not a stateThe self-efficiacy, i.
e. empowerment, of the patient is the strategic
goal
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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)
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SOCIALLY ORIENTED PRACTICE the area of public
healthInteraction between social forces
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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
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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)
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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!
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Instead of the EU, Swedish author Torbjörn Säfve
suggested the Sufic Love EmirateGood food,
real clothes, fresh nature, blooming love, and
free art That is Health !!!