5. The Biomedical Model
Throughout the history of Western science the development of biology has gone hand in hand with that of medicine. Naturally then, the mechanistic view of life, once firmly established in biology, has also dominated the attitudes of physicians toward health and illness. The influence of the Cartesian paradigm on medical thought resulted in the so-called biomedical model,* (*The biomedical model is often simply called ihe medical model. However, I shall use the term 'biomedical' lo distinguish it from. conceplual models of other medical systems, such as ihe Chinese, ) which constitutes the conceptual foundation of modern scientific medicine. The human body is regarded as a machine that can be analyzed in terms of its parts; disease is seen as the malfunctioning of biological mechanisms which are studied from the point of view of cellular and molecular biology; the doctor's role is to intervene, either physically or chemically, to correct the malfunctioning of a specific mechanism. Three centuries after Descartes, the science of medicine is still based, as George Engel writes, on 'the notion of the body as a machine, of disease as the consequence of breakdown of the machine, and of the doctor's task as repair of the machine.''
By concentrating on smaller and smaller fragments of the body, modern medicine often loses sight of the patient as a human being, and by reducing health to mechanical functioning, it is no longer able to deal with the phenomenon of healing. This is perhaps the most serious shortcoming of the biomedical approach, Although every practicing physician knows that healing is an essential aspect of all medicine, the phenomenon is considered outside the scientific framework; the term 'healer' is viewed with suspicion, and the concepts of health and healing are generally not discussed in medical schools.
The reason for the exclusion of the phenomenon of healing from biomedical science is evident. It is a phenomenon that cannot be understood in reductionist terms. This applies to the healing of wounds, and even more to the healing of illnesses, which generally involve a complex interplay among the physical, psychological, social, and environmental aspects of the human condition. To reincorporate the notion of healing into the theory and practice of medicine, medical science will have to transcend its narrow view of health and illness. This does not mean that it will have to be less scientific. On the contrary, by broadening its conceptual basis it will become more consistent with recent developments in modern science.
Health and the phenomenon of healing have meant different things in different ages. The concept of health, like the concept of life, cannot be defined precisely, and in fact, the two are closely related. What is meant by health depends on one's view of the living organism and its relation to its environment. As this view changes from one culture to another, and from one era to another, the notions of health also change. The broad concept of health that will be needed for our cultural transformation - a concept that includes individual, social, and ecological dimensions - will require a systems view of living organisms and, correspondingly, a systems view of health2 To begin with, the definition of health given by the World Health Organization in the preamble of its charter may be useful: 'Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.'
Although the WHO definiton is somewhat unrealistic, picturing health as a static state of perfect well-being, rather than a continually changing and evolving process, it conveys the holistic nature of health., which has to be grasped if we are to understand the phenomenon of healing. Through the ages healing has been practiced by folk healers who are guided by traditional wisdom that sees illness as a disorder of the whole person, involving not only the patients body but his mind; his self-image, his dependence on the physical and social environment, as well as his relation to the cosmos and the deities. These healers, who still treat the majority of patients throughout the world, follow many different approaches, which are holistic to different degrees, and they use a wide variety of therapeutic techniques. What they have in common is that they never restrict themselves to purely physical phenomena, as the biomedical model does. Through rituals and ceremonies they attempt to influence the patient's mind, relieving the apprehension that is always a significant component of illness and helping the patient to stimulate the natural healing powers that all living organisms possess. These healing ceremonies usually involve an intense relationship between healer and patient and are often interpreted in terms of supernatural forces channeled through the healer.
In modern scientific terms we could say that the healing process represents the coordinated response of the integrated organism to stressful environmental influences. This view of healing implies a number of concepts that transcend the Cartesian division and cannot be formulated adequately within the framework of current medical science. Because of this, biomedical researchers tend to disregard the practices of folk healers and are reluctant to admit their effectiveness. Such 'medical scientist^ makes them forget that the art of healing is an essential aspect of all medicine, and that even our scientific medicine had to rely on it almost exclusively until a few decades ago, having little else to offer in terms of specific methods of treatment before that time.3
Western medicine emerged from a large reservoir of folk healing and subsequently spread to the rest of the world, where it became transformed to various degrees but still retained its basic biomedical approach, Widi the global extension of the biomedical system, several writers have abandoned the terms 'Western,' 'scientific,' or 'modern,' and are now referring to it as 'cosmopolitan medicine'4 But the 'cosmopolitan' medical system is only one among many others. Most societies show a pluralism of medical systems and medical beliefs, with no sharp dividing line between one system and another. In addition to cosmopolitan medicine and folk medicine, or folk healing, many cultures have developed their own high-tradition medicine. Like cosmopolitan medicine, these systems - Indian, Chinese, Persian, and others - are based on a written tradition, using empirical knowledge and are practiced by a professional elite. Their approach is holistic, if not always in actual practice, then at least in theory. In addition to these systems, all societies have developed a system of popular medicine - beliefs and practices used within a family, or a community, which are passed on by word of mouth and do not require professional healers.
The practice of popular medicine has traditionally been the prerogative of women, since the art of healing in the family is usually associated with the tasks and the spirit of motherhood. Folk healers, typically, are both female and male, with proportions varying from culture to culture. They do not practice within an organized profession but derive their authority from their healing powers - often interpreted as their access to the spirit world - rather than from professional licensing. With the appearance of organized, high-tradition medicine, however, patriarchal patterns assert themselves and medicine becomes male-dominated. This is as true for classical Chinese or Greek medicine as for medieval European medicine, or modem cosmopolitan medicine.
In the history of Western medicine, the grasp of power by a male professional elite involved a long struggle that accompanied the emergence of the rational and scientific approach to health and healing. The outcome of this struggle was not only the establishment of an almost exclusively male medical elite, but also the intrusion of medicine into domains such as childbirth, which had traditionally been the province of women. This trend is now being reversed by the women's movement, which has recognized the patriarchal aspects of medicine as one more manifestation of the control of women's bodies by men, and has come to see the full participation of women in their own health care as one of its central goals.5
The greatest change in the history of Western medicine came with the Cartesian revolution. Before Descartes, most healers had addressed themselves to the interplay of body and soul, and had treated their patients within the context of their social and spiritual environment. As their world views changed over the ages, so did their views of illness and their methods of treatment, but their approaches were usually concerned with the whole patient. Descartes' philosophy changed this situation profoundly. His strict division between mind and body led physicians to concentrate on the body machine and to neglect the psychological, social, and environmental aspects of illness. From the seventeenth century on, progress in medicine closely followed the developments in biology and the other natural sciences. As the perspective ofbiomedical science shifted from the study of bodily organs and their functions to that of cells and, finally, to the study of molecules, study of the phenomenon of healing was progressively neglected, and physicians found it more and more difficult to deal with the interdependence of body and mind.
Descartes himself, although he introduced the separation of mind and body, nevertheless considered the interplay between the two an essential aspect of human nature, and was well aware of its implications for medicine. The union of body and soul was the principal subject of his correspondence with one of his most brilliant disciples, Princess Elizabeth of Bohemia. Descartes considered himself not only the teacher and close friend of the princess, but also her physician, and when Elizabeth suffered from ill health and described her physical symptoms to Descartes, he did not hesitate to diagnose her affliction as being largely due to emotional stress, as we would say today, and to prescribe relaxation and meditation in addition to physical remedies.6 Thus Descartes showed himself to be far less 'Cartesian'than most of today's medical profession.
In the seventeenth century William Harvey explained the phenomenon of blood circulation in purely mechanistic terms, but other attempts to build mechanistic models of physiological functions were far less successful. By the end of the century it was apparent that a straightforward application of the Cartesian approach would not lead to further medical progress, and several countermovements emerged in the eighteenth century, among which the system of homeopathy became the most widespread and most successful.7
The rise of modem scientific medicine began in the nineteenth century witli the great advances made in biology. At the beginning of the century the structure of the human body, even down to minute details, was almost fully known. In addition, rapid progress was being made in the understanding of physiological processes, largely because of the careful experiments carried out by Claude Bernard. Thus biologists and physicians, faithful to the reductionist approach, turned their attention to smaller entities. This trend proceeded in two directions. One was instigated by Rudolf Virchow, who postulated that all illness involved structural changes at the cellular level, thus establishing cellular biology as the basis of medical science. The other direction of research was pioneered by Louis Pasteur who began the intensive study of microorganisms that has occupied biomedical researchers ever since.
Pasteur's clear demonstration of a correlation between bacteria and disease had a decisive impact. Throughout medical history physicians had debated the question whether a specific disease was caused by a single factor or was the result of a constellation of factors acting simultaneously. In the nineteenth century these two views were emphasized by Pasteur and Bernard respectively. Bernard concentra.ed on environmental factors, external and internal, and stressed the view of illness as resulting from a loss of internal balance involving, in general, the concurrence of a variety of factors. Pasteur concentrated his efforts on elucidating the role of bacteria in the outbreak of illness, associating specific types of diseases with specific microbes.
Pasteur and his followers won the debate triumphantly, and as a result the germ theory of disease - the doctrine that specific diseases are caused by specific microbes - was swiftly accepted by the medical profession. The concept of specific etiology*(*Etiology, from the Greek ai'na ('cause'), is a medical term meaning 'cause (or causes) of disease.' ) was formulated precisely by the physician Robert Koch, who postulated a set of criteria needed to prove conclusively that a particular microbe caused a specific disease. These criteria, known as 'Koch's postulates,' have been taught in medical schools ever since.
There were several reasons for such a complete and exclusive acceptance of Pasteur's view. One was the great genius of Louis Pasteur, who was not only an outstanding scientist but a skilled and vigorous debater, with a special flair for dramatic demonstrations. Another reason was the outbreak of several epidemics in Europe at that time, which provided ideal models for demonstrating the concept of specific causation. The most important reason, however, was the fact that the doctrine of specific disease causation fitted perfectly into the framework of nineteenth-century biology.
The Linnean classification of living forms was gaining general acceptance at the beginning of the century, and it seemed natural to extend it to other biological phenomena. The identification of microbes with diseases provided a method for isolating and defining disease entities, and thus a taxonomy of diseases was established not unlike the tax-onomy of plants and animals. Furthermore, the idea of a disease being caused by a single factor was in perfect agreement with the Cartesian view of living organisms as machines whose breakdown can be traced back to the malfunctioning of a single mechanism.
As the reductionist view of disease established itself as a fundamental principle of modern medical science, physicians overlooked the fact that Pasteur's own views on the question of disease causation were much more subtle than the simplistic interpretation given by his followers. Rene Dubos has shown convincingly, with the help of many quotations, that Pasteur's view of life was fundamentally ecological. 8 He was well aware of the effect of environmental factors on the functioning of living organisms, although he did not have time to investigate them experimentally. The primary aim of his research on disease was to establish the causative role of microbes, but he was also intensely interested in what he called the 'terrain,' by which he meant the internal and external environment of the organism. In his study of the diseases of silkworrosi, which led to the germ theory, Pasteur recognized that these diseases resulted from a complex interaction among host, germs, and environment, and he wrote, having completed his research: 'If I were to undertake new studies on the silkworm diseases, I would direct my effort to the environmental conditions that increase their vigor and resistance.'
Pasteups view of human diseases showed the same ecological awareness. He took it for granted that the healthy body exhibits a striking resistance to many types of microbes. He knew very well that every human organism acts as host to a multitude of bacteria, and he pointed out that these can cause damage only when the body is weakened. Thus, in Pasteur's view, successful therapy will often depend on the physician's ability to restore the physiological conditions favorable to natural resistance. 'This is a principle,' wrote Pasteur, 'which must always be present in the mind of the physican or of the surgeon, because it can often become one of the foundations of the art of healing.' Even more boldly, Pasteur suggested that mental states affect resistance to infection: 'How often does it occur that the condition of the patient - his weakness, his mental attitude . . .- form but an insufficient barrier against the invasion of the infinitely small ones.'The founder of microbioiogy had a view of illness broad enough so that he imuitively anticipated mind-body approaches to therapy that have been developed only very recently and are still suspect to the medical establishment.
The doctrine of specific etiology has influenced the development of medicine enormously, from the days of Pasteur and Koch to the present, by shifting the focus of biomedical research from the host and the environment to the study of microorganisms. The resulting narrow view of illness represents a serious flaw of modern medicine which is now becoming increasingly apparent. On the other hand, the knowledge that microorganisms not only affected the development of disease but could also cause the infection of surgical wounds revolutionized the practice of surgery. It led first to the antiseptic system, in which surgical instruments and dressings were sterilized, and subsequently to the aseptic method, in which everything that comes in contact with the wound has to be completely free of bacteria. Together with the technique of general anesthesia, these advances put surgery on an entirely new basis, creating the principal elements of the intricate ritual that has become characteristic of modern surgery.
Advances in biology during the nineteenth century were accompanied by the rise of medical technology. New diagnostic tools, like the stethoscope and instruments for taking blood pressure, were invented and surgical technology became more sophisticated. At the same time the attention of physicians gradually shifted from the patient to the disease. Pathologies were located, diagnosed, and labeled according to a definite system of classification, and were studied in hospitals transformed from medieval 'houses of mercy'into centers of diagnosis, therapy, and teaching. Thus began the trend toward specialization that was to reach its height in the twentieth century.
The emphasis on the precise definition and location of pathologies was also applied to the medical study of menial disorders, for which the word psychiatry* (^Prorn the Greek psyche (*mind') and ietreia ('healing'). ) was coined. Rather than trying to understand the psychological dimensions of mental illness, psychiatrists concentrated their efforts on finding organic causes - infections, nutritional deficiencies, brain damage - for all mental disturbances. This 'organic orientation* in psychiatry was furthered by the fact that in several instances researchers could indeed identify organic origins of mental disorders and were able to develop successful methods of treatment. Although these successes were partial and isolated, they established psychiatry firmly as a branch of medicine, committed to the biomedical model. This turned out to be rather a problematic development in the twentieth century. Indeed, even in the nineteenth century the limited success of the biomedical approach to mental illness inspired an alternative movement - the psychological approach -which led to the founding of the dynamic psychiatry and psychotherapy of Sigmund Freud9 and brought psychiatry much closer to the social sciences and to philosophy.
In the twentieth century the reductionist trend in biomedical science continued. There were outstanding achievements, but some of the triumphs themselves demonstrated the problems inherent in its methods, visible since the turn of the century but now apparent to a great number of people, both within and outside the field of medicine. This has brought the practice of medicine and the organization of health care to the center of public debate and has made it evident to many that its problems are thoroughly intertwined with the other manifestations of our cultural crisis.10
Twentieth-century medicine is characterized by the progression of biology to the molecular level, and by the understanding of various biological phenomena at that level. This progress, as we have seen, has established molecular biology as a general way of thinking in the life sciences, and has consequently made it the scientific basis of medicine. The great successes of medical science in our century have all been based on detailed knowledge of cellular and molecular mechanisms.
The first major advance, which was really the result of further applications and elaborations of nineteenth-century concepts, was the development of a host of drugs and vaccines to combat infectious diseases. Vaccines were found first against bacterial diseases - typhoid, tetanus, diphtheria, and many others - and later against diseases involving viruses. In tropical medicine the combined use of immunization and insecticides (to control disease-transmitting mosquitoes) has resulted in the virtual conquest of three major diseases of the tropics, malaria, yellow fever, and leprosy. At the same time many years of experience in these programs have taught scientists that the control of tropical diseases involves far more than vaccinations and the spraying of chemicals. Since all insecticides are toxic to humans, and since they accumulate in plant and animal tissue, they should be used very judiciously. In addition, detailed ecological research is needed to understand the interdependencies of the organisms and life cycles involved in the transmission and development of each disease. The complexities are such that none of these diseases can be completely eradicated, but they can be effectively controlled by skillful handling of the ecological situation.11
The discovery of penicillin in 1928 ushered in the era of the antibiotics - one of the most dramatic periods of modern medicine - which culminated in the 1950s with the discovery of a profusion of antibacterial agents capable of coping with a wide variety of microorganisms. The other major pharmaceutical novelty, which also appeared in the 1950s, was a broad range of psychoactive drugs, particularly tran-quilizers and antidepressants. With these drugs psychiatrists were able to control a variety of symptoms and behavior patterns ofpsychotics without causing deep clouding of consciousness. This brought about a major transformation in the care of the mentally ill. Techniques of external coercion were now replaced by the subtle internal chains of modern drugs, which dramatically reduced the time of hospitalization and made it possible to treat many people as outpatients. Emhusiasm for these initial successes obscured for a time the fact that psychoactive drugs, besides having a wide range of dangerous side effects, control symptoms but have no effect on the underlying disorders. Psychiatrists are increasingly aware of this, and critical opinions have begun to gain ground over enthusiastic therapeutic claims.
A major triumph of modern medicine came in endocrinology, the study of the various endocrine glands* (*Glands included in the endocrine system are ihe pituitary (in the brain), thyroid (throat), adrenals (kidneys), islets of Langerhans (pancreas), and gonads(genitals), ) and their secretions, known as hormones, which circulate in the bloodstream and regulate a great variety of bodily functions. The outstanding event in this study was the discovery of insulin ( insulin is a hormone secreted by the pancreas glands known as the islets of Langerhans) The isolation of this hormone, together with the recognition that diabetes was associated with insulin deficiency, made it possible to save countless diabetics from almost certain death and allow them to lead a normal life, sustained by regular insulin injections. Another major advance in the study of hormones came with the discovery of cortisone, a substance isolated from the cortex of the adrenal gland which constitutes a potent antiinflammatory agent. Finally, endocrinology provided greater knowledge and understanding of sex hormones, which led to the development of contraceptive pills.
These examples all illustrate the successes as well as the shortcomings of the biomedical approach. In all cases medical problems are reduced to molecular phenomena with the aim of finding a mechanism that is central to the problem. Once this mechanism is understood, it is counteracted by a drug that is often isolated from another organic process whose 'active principle' it is said to represent. By reducing biological functions to molecular mechanisms and active principles in this way, biomedical researchers necessarily limit themselves to partial aspects of the phenomena they study. As a consequence they can achieve only a narrow view of the disorders they investigate and the remedies they develop. All aspects that go beyond this view are considered irrelevant, as far as the disorders are concerned, and are listed as 'side effects' in the case of the remedies. Cortisone, for example, has become known for its many dangerous side effects, and the discovery of insulin, although extremely useful, has focused the attention of clinicians and researchers on the symptoms of diabetes, preventing them from looking for the underlying causes. In view of this state of affairs, the discovery of vitamins may be seen as perhaps the greatest success of biomedical science. Once the importance of these 'accessory food factors' was recognized and their chemical identity established, many nutritional diseases caused by vitamin deficiency, such as rickets and scurvy, could be cured with the greatest ease by appropriate dietary changes.
Detailed knowledge of biological functions at the cellular and molecular levels not only led to the extensive development of drug therapies but was of tremendous help for surgery, allowing surgeons to advance their art to levels of sophistication beyond all previous expectations. To begin with, the three blood groups were discovered, blood transfusions became possible, and a substance that prevented blood clotting was developed. These developments, together with great advances in anesthesia, gave surgeons much more freedom and made them far more adventurous. "With the appearance of antibiotics, protection from infections became much more efficient and made it possible to replace damaged bones and tissues with foreign materials, especially plastics. At the same time, surgeons developed supreme skills and great dexterity in treating tissues and controlling the organising reactions. The new medical technology allowed them to maintain normal physiological processes even during prolonged surgical interventions. In the 1960s Christiaan Barnard transplanted a human heart, and other transplants of organs followed with varying degrees of success. With these developments medical technology not only reached an unprecedented degree of sophistication but also became all-pervasive in modern medical care. At the same time the increasing dependence of medicine on high technology has raised a number of problems which are not only" of a medical or technical nature but involve much broader social, economic, and moral issues.12
In the long rise of scientific medicine, physicians have gained fascinating insights into the intimate mechanisms of the human body and have developed their technologies to an impressive degree of complexity and sophistication. Yet in spite of these great advances of medical science we are now witnessing a profound crisis in health care in Europe and North America. Many reasons are given for the widespread dissatisfaction with medical institutions - inaccessibility of services, lack of sympathy and care, malpractice - but the central theme of all criticism is the striking disproportion, between the cost and effectiveness of modern medicine. Despite a staggering increase in health costs over the past three decades, and amid continuing claims of scientific and technological excellence by the medical profession, the health of the population does not seem to have improved significantly.
The relation between medicine and health is difficult to assess because most health statistics use the narrow, biomedical concept of health, defined as the absence of disease. A meaningful assessment would deal with both the health of the individual and the health of the society; it would have to include mental illnesses and social pathologies. Such a comprehensive view would show that, although medicine has contributed to the elimination of certain diseases, this has not necessarily restored health. In the holistic view of illness physical disease is only one of several manifestations of a basic imbalance of the organism.13 Other manifestations may take the form of psychological and social pathologies, and when the symptoms of a physical disease are effectively suppressed by medical intervention, an illness may well express itself through some of the other modes.
Indeed, psychological and social pathologies have now become major problems of public health. According to some surveys, as many as 25 percent of our population are sufficiently troubled psychologically to be seriously handicapped and in need of therapeutic attention.14 At the same time there has been an alarming rise in alcoholism, violent crimes, accidents, and suicides, all symptoms of social ill health. Similarly, the current serious health problems of children have to be seen as indicators of social illness,ls along with the rise in crime and political terrorism.
On the other hand, there has been a great increase in life expectancy in developed countries over the past two hundred years, and this is often cited as an indication of the beneficial effects of modem medicine. However, this argument is quite misleading. Health has many dimensions, all arising from the complex interplay between the physical, psychological, and social aspects of human nature. In its many facets it mirrors the entire social and cultural system and can never be represented by a single parameter, such as the death rate or the average length of the life span. Life expectancy is a useful statistic but is not sufficient to measure the health of a society. To get a more accurate picture we have to shift our attention from quantity to quality. The increase in life expectancy has resulted primarily from a decline in infant mortality, which in turn is related to the level of poverty, the availability of proper nutrition, and many other social, economic, and cultural factors. Just how these multiple forces combine to affect infant mortality is still poorly understood, but it has become apparent that medical care has played almost no role in its decline.16
What, then, is the relation between medicine and health? To what extent has modern Western medicine been successful in curing disease and in alleviating pain and suffering? Opinions tend to vary considerably and have led to a number of conflicting affirmations. For example, the following statements can be found in a recent study of health in the United States, sponsored by the Johnson Foundation and the Rockefeller Foundation:
We have developed the finest biomedical research effort in the world, and our medical technology is second to none.—John H. Knowles, President, Rockefeller Foundation
In most instances, we are relatively ineffective in preventing disease or preserving health by medical intervention.—David E. Rogers, President, Robert Wood Johnscn Foundation
... the remarkable, almost unimaginable progress medicine has in fact made in recent decades ...—Daniel Callahan, Director,
Institute of Society, Ethics and the Life Sciences, Hastings-on-Hudson, New York
We are left with approximately the same roster of common major diseases which confronted the country in 1950 and, although we have accumulated a formidable body of information about some of l hem in the intervening time, the accumulation is not yet sufficient to permit either the prevention or the outright cureofany of them.—Lew is Thorn as, President, Memorial SLoan-Kenering Cancer Center
The best estimates are that the medical system (doctors., drugs, hospitals) affects about 10 percent of the usual indices for measuring health.—Aaron Wildavsky, Dean,
Graduate School of Public Policy, U. C. Berkeley'17
These seemingly contradictory statements became intelligible when we realize that different people refer to different phenomena when they speak about progress in medicine. Those who say that there has been progress mean the scientific advances in unraveling biological mechanisms, associating them with specific diseases and developing technologies that will affect them. Indeed, biomedical science has made considerable progress in that sense over the past decades. However, since biological mechanisms are very rarely the exclusive causes of illness, understanding them does not necessarily mean making progress in health care. Hence those who say that medicine has made very little progress over the past twenty years are also right. They are talking about healing rather than scientific knowledge. The two kinds of progress are, of course, not incompatible. Bbmedical research will remain an important part of future health care, while being integrated into a broader, holistic approach.
In discussing the relation between medicine and health, one also has to realize that there is a whole spectrum of medicine, from general practice to emergency medicine, surgery to psychiatry. In some of these areas the biomedical approach has been highly successful whereas in others it has proven to be rather ineffective. The great success of emergency medicine in dealing with accidents, acute infections, and premature births is well known. Almost everyone knows somebody whose life has been saved, or whose pain and discomfort have been dramatically reduced, by medical intervention. Indeed, our modern medical technologies are superb in dealing with these emergencies. But although such medical care can be decisive in individual cases, it does not seem to make a significant difference for the health of populations as a whole.18 The great publicity given to such spectacular medical procedures as open-heart surgery and organ transplants tends to make us forget that many of these patients would not have been hospitalized in the first place if preventive measures had not been severely neglected.
A dramatic development in the history of public health, for which modern medicine is usually given credit, has been the sharp decline in infectious diseases during the late nineteenth and early twentieth centuries. A hundred years ago diseases like tuberculosis, cholera, and typhoid were a constant threat. Anyone could catch them at any time, and every family anticipated losing at least one of its children. Today most of these diseases have almost completely disappeared in developed countries, and the very rare occurrences can easily be controlled with antibiotics. The fact that this dramatic change has taken place more or less simultaneously with the rise of modern scientific medicine has led to the widespread belief that it was brought about by the achievements of medical science. This belief, although shared by most doctors, is quite erroneous. Studies of the history of disease patterns have shown conclusively that the contribution of medical intervention to the decline of the infectious diseases has been much smaller than is generally believed. Thomas McKeown, a leading authority in the fields of public health and social medicine, has made one of the most detailed studies of the history of infections.19 His work provides ample evidence that the striking decline in mortality since the eighteenth century has been due mainly to three effects. The earliest and, over the whole period, most important influence was a vast improvement in nutrition. From the end of the seventeenth century, food production increased rapidly throughout the Western world; there were great advances in agriculture, and the resulting expansion of food supplies made people more resistant to infections. The critical role of nutrition in strengthening the response of the organism to infectious disease is now well established and is consistent with the experience of Third World countries, where malnutrition is recognized as the predominant cause of ill health.20 The second major reason for the decline of infectious diseases is the improvement in hygiene and sanitation of the second half of the nineteenth century. The nineteenth century not only brought us the discovery of microorganisms and the germ theory of disease; it was also the era in which the influence of the environment on human life became a focal point of scientific thought and public awareness. Lamarck and Darwin saw the evolution of living organisms as the result of environmental pressure; Bernard emphasized the importance of the milieu interiew, and Pasteur was intrigued by the 'terrain' in which microbes were active. In the social domain a similar preoccupation with the environment produced popular health movements and sanitary crusades promoting public health and hygiene.
Most nineteenth-century public health reformers did not believe in the germ theory of disease but assumed that bad health originated from poverty, malnutrition, and filth, and they organized vigorous public health campaigns to combat these conditions. This led to improvements in personal hygiene and nutrition and to the introduction of new sanitary measures - purification of water, efficient disposal of sewage, provision of safe milk, and improved food hygiene - all extremely efficient in controlling the infectious diseases. There was also a significant decline in birth rates, which was itself related to the general improvement of living conditions.21 This reduced the rate of population growth and thus insured that the improvement in health would not be jeopardized by rising numbers.
McKeown's analysis of the various factors that influenced mortality from infections shows quite clearly that medical intervention was much less important than others. The major infectious diseases had all peaked and declined well before the first effective antibiotics and immunization techniques were introduced. This lack of correlation between the change of disease patterns and medical intervention has also found striking confirmation in several experiments in which modern medical technologies were used unsuccessfully to improve the health of various 'underdeveloped' populations in the United States and elsewhere.22 These experiments seem to indicate that medical technology alone is unable to bring about significant changes in basic disease patterns.
The conclusion to be drawn from these studies of the relation between medicine and health seems to be that biomedi-cal interventions, although extremely helpful in individual emergencies, have very little effect on the health of entire populations. The health of human beings is predominantly determined not by medical intervention but by their behavior, their food, and the nature of their environment. Since these variables differ from culture to culture, each culture has its own characteristic illnesses, and as food, behavior, and environmental situations gradually change, so do the patterns of disease. Thus the acute infectious diseases that plagued Europe and North America in the nineteenth century, and that are still the major killers in the Third World today, have been replaced in the industrialized countries by illnesses no longer associated with poverty and deficient living conditions but, on the contrary, with affluence and technological complexity. These are the chronic and degenerative diseases - heart disease, cancer, diabetes - that have aptly been called 'diseases of civilization,' since they are closely related to the' stressful attitudes, rich diet, drug abuse, sedentary living, and environmental pollution characteristic of modern life.
Because of their difficulties in dealing with degenerative diseases within the biomedical framework, physicians, rather than enlarging this framework, often seem to resign themselves to accepting these diseases as inevitable consequences of general 'wear-and-tear* for which there is no cure. By contrast, the public has become increasingly dissatisfied with the present system of medical care, noticing painfully that it has generated exorbitant costs without significantly improving people's health, and complaining that doctors treat diseases but are not interested in the patients.
The causes of our health crisis are manifold; they can be found both within and without medical science, and are inextricably linked to the larger social and cultural crisis. Still, increasing numbers of people, both within and outside the medical field, perceive the shortcomings of the current health care system as being rooted in the conceptual framework that supports medical theory and practice, and have come to believe that the crisis will persist unless this framework is modified.23 So it is useful to study in some detail the conceptual basis of modern scientific medicine, the biomedi-cal model, to see how it affects the practice of medicine and the organization of health care.24
Medicine is practiced in many different ways by men and women with different personalities, attitudes, and beliefs. The following characterization therefore does not apply to all physicians, medical researchers, or institutions. There is great variety within the framework of modern scientific medicine; some family physicians are very caring and others care very little; there are surgeons who are highly spiritual and practice their art with a profound reverence for the human condition, and there are others who are cynical and profit-motivated; there are very human experiences in hospitals, and there are others that are inhuman and degrading. In spite of this wide variety, however, one general belief system underlies current medical education, research, and institutional health care. This belief system is based on the conceptual model we have described historically.
The biomedical model is firmly grounded in Cartesian thought. Descartes introduced the strict separation of mind and body, along with the idea that the body is a machine that can be understood completely in terms of the arrangement and functioning of its parts. A healthy person was like a well-made clock in. perfect mechanical condition, a sick person like a clock whose parts were not functioning properly. The principal characteristics of the biomedical model, as well as many aspects of current medical practice, can be traced back to this Cartesian imagery.
Following the Cartesian approach, medical science has limited itself to the attempt of understanding the biological mechanisms involved in an injury to various parts of the body. These mechanisms are studied from the point of view of cellular and molecular biology, leaving out all influences of nonbiological circumstances on biological processes. Out of the large network of phenomena that influence health, the biomedical approach studies only a few physiological aspects. Knowledge of these aspects is, of course, very useful, but they represent only a small part of the story. Medical practice, based on such a limited approach, is not very effective in promoting and maintaining good health. In fact its practices now quite often cause suffering and disease, according to some critics, even more than they cure.25 This will not change until medical science relates its study of the biological aspects of illness to the general physical and psychological condition of the human organism and its environment.
Like physicists in their study of matter, medical scientists have tried to understand the human body by reducing it to basic 'building blocks' and fundamental functions. As Donald Fredrickson, director of the National Institutes of Health, says, 'The reduction of life in all its complicated forms to certain fundamentals that can then be resynthesized for a better understanding of man and his ills is the basic concern of biomedical research.'^In this reductionist spirit medical problems are analyzed by proceeding to smaller and smaller fragments - from organs and tissues to cells, then to cellular fragments, and finally to single molecules - and all too frequently the original phenomenon itself is lost on the way. The history of modern medical science has shown again and again that the reduction of life to molecular phenomena is not sufficient for understanding the human condition in health and illness.
Confronted with environmental or social problems, medical researchers often argue that these are outside the boundaries of medicine. Medical education, so the argument goes, must by definition be dissociated from social concerns, since those are caused by forces over which physicians have no control.27 But doctors have played a major part in bringing about this dilemma by insisting that they alone are qualified to determine what constitutes illness and to select the appropriate therapy. As long as they maintain their positions at the top of the hierarchy of power within the health care system, they will have the responsibility of being sensitive to all aspects of health.
Public health interests are generally isolated from medical education and practice, which are severely imbalanced by the overemphasis on biological mechanisms. Many issues that are crucial to health - such as nutrition, employment, population density, and housing - are not sufficiently discussed in medical schools, and thus there is little room for preventive health care in contemporary medicine. When physicians talk about disease prevention they often do so within the mechanistic framework of the biomedical model, but preventive measures within such a limited framework can, of course, not go very far. John Knowles, president of the Rockefeller Foundation, says bluntly, 'The basic biological mechanisms of most of the common diseases are still not well enough known to give clear direction to preventive measures.'28
What is true for the prevention of illness is also true for the art of healing the sick. In both cases physicians have to deal with whole individuals and their relation to the physical and social environment. Although the art of healing is still widely practiced, both within and outside medicine, this is not explicitly acknowledged in our medical institutions. The phenomenon of healing will be excluded from medical science as long as researchers limit themselves to a framework that does not allow them to deal significantly with the interplay of body, mind, and environment.
The Cartesian division has influenced the practice of health care in several important ways. First, it has split the profession into two separate camps with very little communication between them. Physicians are concerned with the treatment of the body, psychiatrists and psychologists with the healing of the mind. The gap between the two groups has been a severe handicap in the understanding of most major diseases, because it has prevented medical researchers from studying the roles of stress and of emotional states in the development of illness. Stress has only very recently been recognized as a significant source of a wide range of diseases and disorders, and the link between emotional states and illness, although known throughout the ages, still receives little attention from the medical profession.
As a result of the Cartesian split, there are now two distinct bodies of literature in health research. In the psychological literature the relevance of emotional states to illness is widely discussed and well documented. This research is carried out by experimental psychologists and reported in psychology journals that biomedical scientists rarely read. For its part, the medical literature is well grounded in physiology but hardly ever deals with the psychological aspects of illness. Cancer studies are typical. The connection between emotional states and cancer has been well known since the late nineteenth century, and the evidence reported in the psychological literature is substantial. But very few physicians are aware of this work, and medical scientists have not integrated the psychological data into their research.29
Another phenomenon that is poorly understood because of the inability of biomedical scientists to integrate physical and psychological elements is the phenomenon of pain.30 Medical researchers still do not know precisely what causes pain, nor do they fully understand its pathways of communication between body and mind. Just as illness as a whole has physical and psychological aspects, so does the pain which is often associated with it. In practice it is frequently impossible to know which sources of pain are physical and which psychological; of two patients with identical physical symptoms, one may be in excruciating pain while the other experiences none at all. To understand pain, and to be able to alleviate it in the process of healing, we must see its wider context, which includes the patient's mental attitudes and expectations, belief system, emotional support from family and friends, and many other circumstances. Instead of dealing with pain in this comprehensive way, current medical practice, operating within the narrow biomedical framework, tries to reduce pain to an indicator of specific physiological breakdown. Most of the time pain is dealt with by means of denial, and is suppressed with the help of pain killers.
A person's psychological state, of course, is not only relevant in the generation of illness but crucial to the process of healing. The patient's psychological response to the physician is an important part, perhaps the most important part, of every therapy. To induce peace of mind and confidence in the healing process has always been a major purpose of the therapeutic encounter between doctor and patient, and it is well known among physicians that this is usually done intuitively and has nothing to do with technical skills. As Leonard Shiain, himself an outstanding surgeon, observes, "Some doctors seem to make people well, while others, regardless of their expertise, have high rates of complications. The art of healing cannot be quantified.'31
In modern medicine psychological problems and problems of behavior are studied and treated by psychiatrists.
Although they are M.D.s with formal training, there is very little communication between them and physicians outside psychiatry, between mental health professionals and physical health professionals. Many doctors even look down on psychiatrists and consider them second-class physicians. This shows once again the power of the biomedical dogma. Biological mechanisms are seen as the basis of life, mental events as secondary phenomena. Physicians who deal with mental illness are considered somehow less important.
In many cases, psychiatrists have reacted to this attitude by adhering rigorously to the biomedical model and trying to understand mental illness in terms of a derangement of underlying physical mechanisms in the brain. According to this view, mental illness is basically the same as physical illness;
the only difference is that it affects the brain rather than some other organ of the body, and thus manifests itself through mental rather than physical symptoms. This conceptual development has led to a rather curious situation. Whereas healers through the ages have tried to treat physical illness by psychological means, modern psychiatrists now treat psychological illness by physical means, having convinced themselves that mental problems are diseases of the body.
The organic orientation in psychiatry has resulted in the transplantation of concepts and methods that have been found useful in the treatment of physical diseases into the field of emotional and behavioral disorders. Since these disorders are believed to be based on specific biological mechanisms, great emphasis is placed on establishing the correct diagnosis using a reductionist system of classification. Although this approach has failed for most mental disorders, it is still widely pursued in the hope of finding, ultimately, the specific mechanisms of disease causation and the corresponding specific methods of treatment for all mental disorders.
As for treatment, the preferred method is to treat mental illness with medication, which controls the symptoms of the disorder but does not cure it. And it is becoming increasingly apparent that this kind of treatment is couniertherapeutic.
From a holistic perspective of health, mental illness can be seen as resulting from a failure to evaluate and integrate experience. In this view the symptoms of a mental disorder reflect the organism's attempt to heal itself and achieve a new level of integration.32 Standard psychiatric practice interferes with this spontaneous healing process by suppressing the symptoms. True therapy would consist in facilitating the healing by providing an emotionally supportive atmosphere for the patient. Rather than being suppressed, the process that constitutes a symptom would be allowed to intensify in such an atmosphere, and continuing self-exploration would lead to its full experience and conscious integration, thus completing the healing process.
To practice such a therapy, considerable knowledge of the full spectrum of human consciousness is required. Psychiatrists often lack such knowledge, yet they are legally responsible for the treatment of mental patients. Accordingly, mental patients are treated in medical institutions where clinical psychologists, who often have a much more thorough knowledge of psychological phenomena, act merely as ancillary personnel subordinated to psychiatrists.
The extension of the biomedical model to the treatment of mental disorders has been, on the whole, very unfortunate. Although the biological approach has been useful for the treatment of some disorders with a clear organic origin, it is quite inappropriate for many others to which psychological models are of fundamental significance. A great deal of effort has been wasted in trying to arrive at a precise, organically based diagnostic system of mental disorders, without the realization that the search for accurate, objective diagnosis will ultimately be futile for most psychiatric cases. The practical disadvantage of this approach has been that many individuals with no organic malfunctions are treated in medical facilities where they receive therapies of problematic value at extremely high costs.
The limitations of the biomedical approach to psychiatry are now becoming apparent to an increasing number of health professionals, and these practitioners are engaged in a lively debate about the nature of mental illness. Thomas Szasz, who regards mental illness as pure myth, takes perhaps the most extreme position.33 Szasz condemns the notion of illness as something that attacks people without any relation to their personalities, life styles, belief systems, or social environment. In this sense all illness, whether mental or physical, is a myth. If the term is used in a holistic sense, taking into account the patient's entire organism and personality, as well as the physical and social environment, mental disorders are as real as physical illnesses. But such an understanding of mental illness transcends the conceptual framework of current medical science.
Avoidance of the philosophical and existential issues that arise in connection with every serious illness is a characteristic aspect of contemporary medicine. It is another consequence of the Cartesian division that has led medical scientists to concentrate exclusively on the physical aspects of health. In fact the question "What is health?" is generally not even addressed in medical schools, nor is there any discussion of healthy attitudes and life styles. These are considered philosophical issues that belong to the spiritual realm, outside the domain of medicine. Furthermore, medicine is supposed to be an objective science, not concerned with moral judgments.
This seventeenth-century view of medical science often prevents physicians from seeing the beneficial aspects and potential meaning of illness. Disease is viewed as an enemy to be conquered, and medical scientists pursue the Utopian ideal of eliminating, eventually, all diseases through the application of biomedical research. Such a narrow point of view fails to comprehend the subtle psychological and spiritual aspects of illness, and prevents medical researchers from realizing, as Dubos has noted, that "complete freedom from disease and struggle is almost totally incompatible with the living process.'34
The ultimate existential issue is, of course, death - and, like all other philosophical and existential questions, the matter of death is avoided as much as possible. The tack of spirituality that has become characteristic of our modern technological society is reflected in the fact that the medical profession, like society as a whole, is death-denying. Within the mechanistic framework of our medical science, death cannot be qualified. The distinction- between a good death and a poor death does not make sense; death becomes simply the total standstill of the body-machine.
The age-old art of dying is no longer practiced in our culture, and the fact that it is possible to die in good health seems to have been forgotten by the medical profession. Whereas in the past one of the most important roles of a good doctor was lo provide comfort and support for dying patients and their families, physicians and other health professionals today are no longer trained to deal with dying patients and find it extremely difficult to cope with the phenomenon of death in a meaningful way. They tend to see death as a failure; bodies are carried out of hospitals secretly at night, and doctors seem significantly more afraid of death than other people, whether sick or healthy. ^Although general attitudes toward death and dying have recently begun to change considerably,36 following the spiritual renaissance of the 1960s and 1970s, the new attitudes have not yet been incorporated into our health care system. To do so will require a fundamental conceptual shift in the medical view of health and illness.
Having discussed some of the consequences of the Cartesian division for contemporary medicine, let us now take a closer look at the image of the body as a machine and its impact on current medical theory and practice. The mechanistic view of the human organism has encouraged an engineering approach to health in which illness is reduced to mechanical trouble and medical therapy to technical manipulation.37 In many cases this approach has been successful. Medical science and technology have developed highly sophisticated methods for removing or repairing various parts of the body, and even for replacing them by artificial constructs. This has alleviated the suffering and discomfort of countless victims of illnesses and accidents, but it has also helped to distort the views of health and health care held by the medical profession and the general public.
The public image of the human organism - enforced by the content of television programs, and especially by advertising - is that of a machine which is prone to constant failure unless supervised by doctors and treated with medication. The notion of the organism's inherent healing power and tendency to stay healthy is not communicated, and trust in one's own organism is not promoted. Nor is the relation between health and living habits emphasized; we are encouraged to assume that doctors can fix anything, irrespective of our life styles.
It is intriguing and quite ironic that physicians themselves are the ones who suffer most from the mechanistic view of health by disregarding stressful circumstances in their lives. Whereas traditional healers were expected to be healthy people, keeping their body and soul in harmony and in tune with their environment, the typical attitudes and habits of doctors today are quite unhealthy and produce considerable illness. Physicians'1 life expectancy today is ten to fifteen years less than that of the average population, and they have not only high rates of physical illness but also high rates of alcoholism, drug abuse, suicide, and other social pathologies.38
Most doctors adopt their unhealthy attitudes right at the beginning of medical school, where their training has been designed to be a highly stressful experience. The unhealthy value system that dominates our society has found some of its most extreme expressions in medical education. Medical schools, especially in the United States, are by far the most competitive of all professional schools. Like the business world, they present high competitiveness as a virtue and emphasize an "aggressive approach' to patient care. In fact the aggressive stance of medical care is often so extreme that the metaphors used to describe illness and therapy are taken from the language of warfare. For example, a malignant tumor is said to 'invade' the body, radiation therapy 'bombards' the tissues to 'kill" the cancer cells, and chemotherapy is often likened to chemical warfare. Thus medical education and practice perpetuate the attitudes and behavior patterns of a value system that plays a significant role in causing many of the diseases medicine seeks to cure.
Medical schools not only generate stress but also neglect to teach their students how to cope with it. The essence of current medical training is inculcating the notion that the patient's concerns come first and that the doctors well-being is secondary. This is thought to be necessary to produce commitment and responsibility, and to foster such an attitude the medical training consists of extremely long hours with very few breaks. Many physicians continue this practice in their professional lives. It is not uncommon for a physician to work for a full year with no vacation. This excessive stress is aggravated by the fact that doctors continually have to deal with people in states of high anxiety or deep depression, which adds further intensity to their daily work. On the other hand, they are trained to use a model of health and illness in which emotional forces play no role, and hence they tend to disregard them in their own lives.
The mechanistic view of the human organism and the resulting engineering approach to health has led to an excessive emphasis on medical technology, which is perceived as the only way to improve health. Lewis Thomas, for example, is quite explicit about this in his paper ^Oa the Science and Technology of Medicine.'After his remark that medicine has not been able to prevent or cure any of our common major diseases over the past three decades, he goes on to say, 'We are, in a sense, stuck with today's technology, and we will stay stuck until we have more scientific knowledge to work with it.'39
Hard technology has taken a central role in modern medical care. At the turn of the century the ratio of supporting personnel to doctors was about one to two; now it can be as high as fifteen to one. The diagnostic and therapeutic tools operated by this army of technicians are the result of recent advances in physics, chemistry, electronics, computer science, and other related fields. They include computerized blood analyzers and tomography scanners.,* (*The computerized tomography scanner, or 'CAT scanner,' is a machine used for X-ray diagnosis of abnormalities within the skull. It consists of an X-ray unit directing beams through the skull from multiple directions, coupled to a computer that analyzes the X-ray information and constructs visual images (hat could not be obtained by conventional techniques. ) machines for renal dialysis, (+A renal dialysis machine filters or 'dialyzes' the blood of patients with kidney failure, replacing the function of the kidneys. )! cardiac pacemakers, equipment for radiation therapy, and many other machines that are not only highly sophisticated but also extremely expensive, some of them costing close to a million dollars.40 As in other areas, the use of high technology in medicine is often unwarranted. The increasing dependence of medical care on complex technologies has accelerated the trend toward specialization and has enforced the doctors' tendency to look at particular parts of the body, forgetting to deal with the patient as a whole person.
At the same time the practice of medicine has shifted from the office of the general physician to the hospital where it became progressively depersonalized, if not dehumanized. Hospitals have grown into large professional institutions, emphasizing technology and scientific competence rather than contact with the patient. In these modern medical centers, which look more like airports than therapeutic environments, patients tend to feel helpless and frightened, which often keeps them from getting well. Some 30 to 50 percent of present hospitalizadon is medically unnecessary, but alternative services that could be therapeuiically more effective and economically more efficient have almost disappeared.41
The costs of medical care have increased at a frightening pace over the past three decades. In the United States, they went up from twelve billion dollars in 1950 to a hundred and sixty billion in 1977, rising almost twice as fast as the cost of living during 1974-77.42 Similar tendencies have been observed in most other countries, including those with socialized medical systems. The development and widespread use of expensive medical technologies is one of the main reasons for this sharp increase in health costs. For example, renal dialysis for one individual may cost as much as $10,000 a year, and coronary bypass surgery, which has yet to be shown to prolong life, is being performed thousands of times at a cost of $10,000 to $25,000 per operation.'"
The excessive use of high technology in medical care is not only uneconomic but also causes an unnecessary amount of pain and suffering. Accidents in hospitals now occur more frequently than in any other industries except mining and high-rise construction. It has been estimated that one out of every five patients admitted to a typical research hospital will acquire an iatrogenic illness,* (*Iairogenic illnesses - from the Greek iairw i,'physician') and genesis (''origin') - are illnesses generated by the medical care process itself. ) with half of these episodes resulting from complications of drug therapy and a surprising 10 percent from diagnostic procedures.44
The high risks of modern medical technology have led to a further significant increase in health costs through the growing number of malpractice suits against physicians and hospitals. There is now an almost paranoid fear of litigation among American doctors, who try to protect themselves from lawsuits by practicing 'defensive medicine,' ordering even more diagnostic technologies which further increase the costs of health care and expose patients to additional risks.45 This malpractice crisis is the result of several things: excessive use of high technology within a mechanistic model of illness in which all responsibility is delegated to the doctor; considerable pressure from a large number of profit-motivated lawyers; and a society that prides itself on being democratic but does not have a socialized medical system.
The conceptual problem at the center of contemporary health care is the biomedical definition of disease, according to which diseases are well-defined entities that involve structural changes at the cellular level and have unique causal roots. The biomedical model allows for several kinds ofcaus alive factors, but researchers tend to adhere to the doctrine of "one disease, one cause." The germ theory was the first example of specific disease causation. Bacteria and, later on, viruses have been assumed to be the cause of virtually every disease of unknown origin. Then the rise of molecular biology brought the concept of the single lesion,* ("Lesion - a technical term for injury; it denotes an abnormal change in structure of an organ or other bodilypart. ) which includes genetic anomalies; and more recently environmental causes of disease have come under study. In all these cases medical scientists have tried to achieve three objectives: precise definition of the disease under study; identification of its specific cause; and development of the appropriate treatment - usually some technical manipulation - that will eliminate the causal root of the disease.
The theory of specific disease causation has been successful in a few special cases, such as acute infectious processes and nutritional deficiencies, but the overwhelming majority of illnesses cannot be understood in terms of the reductionist concepts of well-defined disease entities and single causes. The main error of the biomedical approach is the confusion between disease processes and disease origins. Instead of asking why an illness occurs, and trying to remove the conditions that lead to it, medical researchers try to understand the biological mechanisms through which the disease operates, so that they can then interfere with them. Among the leading contemporary researchers Thomas has expressed his belief in such an approach with unusual clarity: Tor every disease there is a single key mechanism that dominates all others. If one can find it, and then think one's way around it, one can control the disorder ... In short, I believe that the major diseases of human beings have become approachable biological puzzles, ultimately solvable.'46
These mechanisms, rather than the true origins, are seen as the causes of disease in current medical thinking, and this confusion lies at the very center of the conceptual problems of contemporary medicine. As Thomas McKeown has emphasized, 'It should be recognized that the most fundamental question in medicine is why disease occurs rather than how it operates after it has occurred; that is to say, conceptually the origins of disease should take precedence over the nature of disease process.'47
The origins of disease will generally be found in several causative factors that must concur to result in ill health.48 Moreover, their effects will differ profoundly from person to person, since they depend on the individual's emotional reactions to stressful situations and on the social environment in which these situations occur. The common cold is a good example. It can develop only if a person is exposed to one of several viruses, but not everybody exposed to these viruses will be afflicted. Exposure will result in illness only when the exposed individual is in a receptive state, and this will depend on weather conditions, fatigue, stress, and a host of other circumstances that influence the person's resistance to infection. To understand why a particular person develops a cold, many of these factors have to be assessed and weighed against one another. Only then will the 'puzzle of the common cold' be solved.
This situation has its counterpart in almost all illnesses, most of them far more serious than the common cold. An extreme case, in both complexity and severity, is cancer. Over the past decades huge amounts of money have been poured into cancer research with the aim of identifying a virus that causes the disease. When this line of research remained fruitless, attention shifted to environmental causes, which were also investigated within a reductionist framework. Today many researchers still perpetuate the impression that exposure to a carcinogenic substance alone causes cancer. But if we look at the number of people who are exposed, for example, to asbestos and ask how many of them will develop lung cancer, we find that the incidence is something like one in a thousand. Why does that one person develop the disease? The answer is that any noxious influence from the environment involves the organism as a whole, including the psychological state and the social and cultural conditioning of the person. All these factors are significant in the development of cancer and have to be taken into account to understand the disease.
The concept of disease as a well-defined entity has led to a classification of diseases patterned after the taxonomy of plants and animals. Such a classification system has some justification for illnesses with predominantly physical symptoms, but it is extremely problematic for mental illnesses, to which it has been extended. Psychiatric diagnosis is notorious for its lack of objective criteria. Since the patient's behavior toward the psychiatrist is part of the clinical picture on which the diagnosis is based, and since this behavior is influenced by the doctor's personality, attitudes, and expectations, the diagnosis will necessarily be subjective. Thus the ideal of a precise classification of 'mental disease' remains largely illusory. Nevertheless, psychiatrists have spent an enormous amount of effort trying to establish objective diagnostic systems for emotional and behavioral disorders that would allow them to include mental illness in the biomedical definition of disease.
In the process of reducing illness to disease, the attention of physicians has moved away from the patient as a whole person. Whereas illness is a condition of the total human being, disease is a condition of a particular part of the body, and rather than treating patients who are ill, doctors have concentrated on treating their diseases.49 They have lost sight of the important distinction between the two concepts. According to the biomedical view, there is no illness, and thus no iustifi-cation for medical attention, without the structural or biochemical alterations characteristic of a specific disease. But clinical experience has shown repeatedly that one can be ill without having a disease. Half of all visits to the doctor are for complaints that cannot be associated with any physiological disorder.50
Because of the biomedical definition of disease as the basis of illness, medical treatment is directed exclusively at the biological abnormality. But this does not necessarily restore the patient to health, even if the treatment is successful. For example, medical cancer therapy may result in the complete regression of a tumor without making the patient well. Emotional problems may continue to affect the patient's health and, if not dealt with, may produce a recurrence of the malignancy,51 On the other hand, it may happen that apatient has no demonstrable disease but nevertheless feels quite sick. Because of the limitations of the biomedical approach, physicians are often unable to help such patients, who have been called 'the worried well.'
Although the biomedical model distinguishes between symptoms and diseases, each disease itself, in a wider sense, can be seen as merely a symptom of an underlying illness whose origins are rarely investigated. To do so would require seeing ill health within the broad context of the human condition, recognizing that any illness or behavioral disorder of a particular individual can be understood only in relation to the whole network of interactions in which that person is embedded.
Perhaps the most striking example of the emphasis on symptoms rather than underlying causes is the drug approach of contemporary medicine. It has its roots in the erroneous view that bacteria are the primary causes of disease, rather than symptomatic manifestations of underlying physiological disorder. For many decades after Pasteur advanced his germ theory medical research was focused on the bacteria and neglected to study the host organism and its environment. Because of this one-sided emphasis, which began to change only in the second half of our century with the rise of immunology, physicians have tended to concentrate on destroying the bacteria instead of looking for the causal roots of the disorder. They have been very successful in suppressing or alleviating the symptoms but at the same time often cause further damage to the organism.
The overemphasis on bacteria has given rise to the view that disease is the consequence of an attack from outside, rather than of a breakdown within the organism. Lewis Thomas, in hi& popular Lives of a Cell, has given a vivid description of this widespread misconception:
Watching television, you'd think we lived at bay, in total jeopardy, surrounded on all sides by human-seeking germs, shielded against infection and death only by a chemical technology that enables us to keep killing them off- We are instructed to spray disinfectants everywhere . . . We apply potent antibiotics to minor scratches and seal them with plastic. Plastic is the new protector; we wrap the already plastic tumblers of hotels in more plastic, and seal the toilet seats like state secrets after irradiating them with ultraviolet light. We live in a world where the microbes are always trying to get at us, to tear us cell from cell, and we only stay alive through diligence and fear.52
These rather grotesque attitudes, more noticeable in the United States than anywhere else, are of course promoted not only by medical science but even more forcefully by the chemical industry. Whatever their motivation, they are hardly Justified on the basis of biological fact. It is well known that many types of bacteria and viruses associated with disease are commonly present in the tissues of healthy individuals without causing any harm. Only under special circumstances that lower the general resistance of the host do they produce pathological symptoms. Our society makes it hard to believe, but the functioning of many essential organs requires the presence of bacteria. Animals raised under totally germ-free conditions have been shown to develop gross anatomical and physiological abnormalities.5i
Out of the huge population of bacteria on the earth, only a small number is capable of generating diseases in human organisms, and these are usually destroyed in due course by the organism's immune mechanisms. As Thomas says, 'The man who catches a meningococcus* (*Menmgococcus is the bacterium associated with meningitis, an inflammation of i he membranes covering the brain and spinal cord. ) is in considerably less danger for his life, even without chemotherapy, than the meningococci with the bad tuck to catch a man.'54 On the other hand, bacteria that are relatively harmless for a oarticular group of people who have built up resistance to them may be extremely virulent for others if they have never been exposed to these microbes before, The catastrophic epidemics that afflicted Polynesians, American Indians, and Eskimos at their first contacts with European explorers provide striking illustrations of this.55
The point is that the development of infectious diseases depends as much on the response of the host as on the specific characteristics of the bacteria. This view is further enforced by a careful study of the detailed mechanism of infection. There seem to be very few infectious diseases in which the bacteria cause actual direct damage to the cells or tissues of the host organism. There are some, but in most cases the damage is caused by an overreacdon of the organism, a kind of panic in which a number of powerful, unrelated defense mechanisms are all turned on at once.56 Infectious diseases, then, arise most of the time from a lack of coordination within the organism, rather than from injury caused by invading bacteria,
Given these facts, it would seem extremely useful, and as intellectually challenging, to study the complex interactions of mind, body, and environment that affect resistance to bacteria. However, very little research of this kind is being done. The major research effort in. this century has been directed toward identifying specific microorganisms and developing medicines to kill them. This effort has been extremely successful, providing doctors with an arsenal of drugs that are highly effective in the treatment of acute bacterial infections. But while the proper use of antibiotics in emergency situations will continue to be justified, it will also he essential to study and enhance the natural resistance of human organisms to bacteria.
Antibiotics, of course, are not the only type of drugs used in modern medicine. Drugs have become the key to all medical therapy. They are used to regulate a wide variety of physiological functions through their effects on nerves, muscles, and other tissues, as well as on the blood and other bodily fluids. Drugs can improve the functioning of the heart and correct irregularities in the heartbeat; they can raise or lower blood pressure, prevent blood clotting or control excessive bleeding, induce muscle relaxation, affect the secretion of various glands, and regulate a number of digestive processes. By acting on the central nervous system, they can alleviate or temporarily eliminate pain, relieve tension and anxiety, induce sleep, or increase alertness. Drugs can affect a wide range of regulatory functions, from the visual accommodation of the eye to the destruction of cancer cells. Many of these functions involve subtle biochemical processes that are barely understood, if not completely mysterious.
The extensive development of chemotherapy* (^Chemotherapy is the treaiment of disease with chemicals, that is, with drugs. ) in modern medicine has allowed physicians to save innumerable lives and alleviate much suffering and discomfort, but, unfortunately, it has also led to the well-known overuse and misuse of drugs, both by doctors through prescription and by individuals through self-medication. Until recently it was believed that the toxic side effects of medical drugs, although sometimes serious, were so rare that they were generally insignificant. This turned out to be a grave misjudgment. During the past two decades adverse drug reactions have become a public health problem of alarming proportions, producing considerable pain and discomfort for millions each year.57 Some of these effects are inevitable, and many of them are clearly the fault of patients, but many others are the result of careless and inappropriate prescriptions by doctors who adhere rigidly to the biomedical approach. It has been argued that high-quality medicine can be practiced without the use of any of the twenty most commonly prescribed drugs. ^8
The central role of drugs in contemporary health care is often justified with the observation that today's most effective drugs - including digitalis, penicillin, and morphine -all come from plants, many of them used as medicines throughout the ages. The medical use of drugs, according to this argument, is merely the continuation of a custom that is probably as old as humanity itself. Although this is certainly true, there is a crucial difference between the use of herbal medicines and chemical drugs. The drugs prepared in modern pharmaceutical laboratories are purified and highly concentrated samples of substances that occur naturally in plants. These purified products turn out to be less efficient and more hazardous than the original unpurified remedies. Recent experiments with herbal medicine indicate that the purified active principle is less effective as a medicine than the crude extract from the plant, because the latter contains trace elements and molecules that were considered unimportant but turn out to play a vital role by limiting the effect of the main active ingredient. They ensure that the body's reaction does not go too far and cause unwanted side effects. Crude extracts of herbal mixtures also have very special antibacterial properties. They do not destroy the bacteria but prevent them from multiplying, so that mutations cannot occur and strains of bacteria resistant to the medication are unlikely to develop.59 Furthermore, the dosage of herbal medicines is much less problematic than that of chemical drugs. Herbal mixtures that have been tried out empirically for thousands of years need not be quantified precisely because of their in-built moderating effects. Approximate dosages, according to age, body weight, and size of the patient, are sufficient. Thus modern science is now validating empirical knowledge that has been passed on from generation to generation by folk healers in all cultures and traditions.
An important aspect of the mechanistic view of living organisms and the resulting engineering approach to health is the belief that the cure of illness requires some outside intervention by the physician, which can be either physical, through surgery or radiation, or chemical, through drugs. Current medical therapy is based on this principle of medical intervention, relying on outside forces for cure, or at least for the alleviation of suffering and discomfort, without taking into account the healing potential within the patient. This attitude derives directly from the Cartesian view of the body as a machine that requires somebody to repair it when it breaks down. Accordingly, medical intervention is carried out with the aim of correcting a specific biological mechanism in a particular part of the body, with different parts treated by different specialists.
To associate a particular illness with a definite part of the body is, of course, very useful in many cases. But modern scientific medicine has overemphasized the reductionist approach and has developed its specialized disciplines to a point where doctors are often no longer able to view illness as a disturbance of the whole organism, nor to treat it as such. What they tend to do is to treat a particular organ or tissue, and this is generally done without taking the rest of the body into account, let alone considering the psychological and social aspects of the patient's illness.
Even though such a fragmentary medical intervention can be very successful in alleviating pain and suffering, this alone is not always enough to justify it. From a broader point of view, not everything that alleviates suffering temporarily is necessarily good. If the intervention is carried out without taking other aspects of the illness into account, the result will generally be unhealthy for the patient in the long run. For example, somebody may develop arteriosclerosis, a narrowing and hardening of the arteries, as the result of an unhealthy way of life - heavy diet, lack of exercise, excessive smoking. Surgical treatment of a blocked artery may temporarily alleviate pain but will not make the person well. The surgical intervention merely treats a local effect of a systemic disorder that will continue until the underlying problems are identified and resolved.
Medical therapy, of course, will always be based on some form of intervention. It need not, however, take the excessive and fragmentary form we see so often in contemporary health care. It could be the kind of therapy practiced by wise physicians and healers for millennia, a subtle interference with the organism to stimulate it in a specific way so that it will, by itself, complete the process of healing. Therapies of chat kind are based on a profound respect for self-healing; on the view of the patient as a responsible individual who can herself initiate the process of getting well. Such an attitude is contrary to the biomedical approach, which delegates all authority and responsibility to the doctor.
According to the biomedical model, only the doctor knows what is important for an individual's health, and only he can do anything about it, because all knowledge about health is rational, scientific knowledge, based on objective observation of clinical data. Thus laboratory tests and measurement of physical parameters in the examining room are generally considered more relevant to the diagnosis than the assessment of the patient's emotional state, family history, or social situation.
The physician's authority and his responsibility for the patient's health make him assume a paternal role. He can be a benevolent parent or a dictatorial parent, but his position is clearly superior to that of the patient. Moreover, since most doctors are men, the paternal role of the physician encourages and perpetuates sexist attitudes in medicine, with respect to both women patients and women doctors.60 These attitudes include some of the most dangerous manifestations of sexism, not provoked by medicine as such but reflecting the patriarchal bias in society as a whole, and especially in science.
In today's health care system physicians play a unique and decisive role in the health teams that share the tasks of patient care.61 It is the physician who sends patients to the hospital and sends them home, who orders tests and X-rays, recommends surgery and prescribes drugs. Nurses, although often highly trained as therapists and health educators, are considered merely assistants of doctors and can rarely use their full potential. Because of the narrow biomedical view of illness and the patriarchal patterns of power in the health care system, the important role that nurses play in the healing process through their human contacts with the patients is not fully recognized. From these contacts nurses often acquire much more extensive knowledge of the patients physical and psychological condition than doctors, but this knowledge is considered less relevant than the.M.D.'s 'scientific^ assessment based on laboratory tests. Spellbound by the mystique that surrounds the medical profession, our society has conferred on physicians the exclusive right to determine what constitutes illness, who is ill and who is well, and what should be done to the sick. Numerous other healers, such as homeopaths, chiropractors, and herbalists, whose therapeutic techniques are based on different, but equally coherent, conceptual models have been legally excluded from the mainstream of health care.
Although physicians have considerable power to influence the health care system, they are also very conditioned by it. Since their training is heavily oriented toward hospital care, they feel more comfortable in doubtful cases when their patients are in the hospital, and since they receive very little reliable information about drugs from noncommercial sources, they tend to be unduly influenced by the pharmaceutical industry. However, the essential aspects of contemporary health care are determined by the nature of medical education. The emphasis on hard technology, the overuse of drugs, and the practice of centralized, highly specialized medical care all originate in the medical schools and academic medical centers. Any attempt to change the current system of health care will therefore have to begin by changing medical education.
American medical education was cast into its present form at the beginning of the century, when the American Medical Association commissioned a national survey of medical schools with the aim of putting medical education on a sound scientific basis. A related purpose of the survey was to channel the huge funds of newly formed foundations - especially those of the Carnegie and Rockefeller foundations - into a few carefully chosen medical institutions.62 This established the link between medicine and big business that has dominated the entire health care system ever since. The result of the survey was the Flexner Report, published in 1910, which decisively shaped American medical education by setting up strict guidelines that are still followed today.63 The modern medical school was to be part of a university, with a permanent faculty committed to teaching and research. Its primary purpose was the education of students and the study of disease, not the care of the sick. Accordingly, the M.D. degree it granted was to certify the successful mastery of medical science, not the ability to care for patients. The science to be taught, and the research to be pursued, were firmly embedded in the reductionist biomedical framework; in particular, they were to be dissociated from social concerns, which were considered outside the boundaries of medicine.
The Flexner Report found that only about 20 percent of all American medical schools met its 'scientific' standards. The others were declared 'second-rate' and were forced to close through legal and financial pressures. Although many of the schools had indeed been inadequate, they were also the institutions that had admitted female, black, and poor students, all now effectively barred from access to medical training. ]n particular, the medical establishment vehemently opposed the admission of women into medicine and erected a number of barricades against the training and practice of female physicians.
Under the impact of the Flexner Report, scientific medicine became more and more biologically oriented, specialized, and hospital-based. '^Specialists increasingly replaced generalists as teachers and became the models for aspiring physicians. By the late 1940s medical students in the academic medical centres had almost no contact with physicians practicing general medicine, and since their training took place more and more within hospitals, they were effectively removed from contact with most of the illnesses that confront people in their daily lives. This situation has persisted to the present day. Whereas two-thirds of the complaints encountered in everyday medical practice are for minor illnesses of brief duration, which usually cure themselves, and less than 5 percent for major illnesses carrying a threat to life, this proportion is reversed in a university hospital.65 Thus medical students are given a thoroughly distorted view of illness. Their major experience involves only a tiny portion of common health problems, and these problems are not studied out in the community, where their broader context could be assessed, but in the hospital, where students concentrate exclusively on the biological aspects of illness. As a consequence, interns and residents develop disdain for the ambulatory patient - the walking, living person with complaints that usually involve emotional as well as physical problems - and come to see the hospital as an ideal place to practice specialized and technology-oriented medicine.
A generation ago more than half of all physicians were general practitioners; now over 75 percent are specialists, confining their attention to a particular age group, disease, or part of the body. According to David Rogers,66 this has resulted in 'the apparent inability of American medicine to deal with the simple day-to-day medical needs of our population.' On the other hand, there is a 'surplus' of surgeons in the United States which, according to some critics, results in considerable overuse of surgical procedures.67 These are some of the reasons why many people see the need for primary health care - the broad range of general care traditionally rendered by physicians in community practice - as the central problem facing American medicine.
The problem with primary care is not only the small number of general practitioners but also their approach to patient care, which is often restricted by the heavily biased training they received in medical school. The task of the general practitioner requires not only scientific knowledge and technical skills but wisdom, compassion, and patience, an ability to provide human comfort and reassurance, sensitivity to the patient's emotional problems, and therapeutic skills in the management of psychological aspects of illness. These attitudes and skills are generally not emphasized in the present programs of medical training, in which the identification and treatment of a specific disease is presented as the essence of medical care. Moreover, medical schools vigorously promote an unbalanced, "macho' value system and actively suppress the qualities of intuition, sensitivity, and nurturance in favor of a rational, aggressive, and competitive approach. As Scott May, a student at the University of California School of Medicine in San Francisco, said in his graduation speech, ^Medical school felt like a family where the mother was gone and only the hard father remained at home.'68 Because of this imbalance, physicians often regard an empathic discussion of personal issues as quite unnecessary, and in turn patients tend to perceive them as cold and unfriendly and complain that the doctor fails to understand their worries.
The purpose of our academic centers is not only training but research. As in medical education, the biological orientation is heavily favored in the support and funding of research projects. Although epidemic logical, social, and environmental research would often be much more useful and efficient for improving human health than the strict biomedical approach,69 projects of this kind are little encouraged and poorly financed. The reason for this resistance is not merely the strong conceptual appeal of the biomedical model to most researchers but also its vigorous promotion by the various interest groups in the health industry.70
Although there is widespread dissatisfaction with medicine and with doctors among the general public, most people are not aware that one of the main reasons for the current state of affairs is the narrow conceptual basis of medicine. On the contrary, the biomedical model is generally accepted, and its basic principles are so thoroughly ingrained in our culture that it has even become the dominant folk model of illness. Most patients do not understand its intricacies very well, but they have been conditioned to believe that the doctor alone knows what made them sick and that technological intervention is the only thing that will get them well.
This public attitude makes it very difficult for progressive physicians to change the patterns of current health care. I know several who try to explain their patients' symptoms to them, relating the illness to the patients' living habits, and who find again and again that patients are not satisfied with that approach. They want something else, and often they will not be content until they can leave the doctor's office with a prescription in their hands. Many physicians make great efforts to change people's attitudes about health, so that they will not insist on. having an antibiotic prescribed for a cold, but the power of the patients' belief system often makes these efforts ineffective. As one general practitioner tells me, 'You have a mother with a child who is running a fever, and who says, "Give him a penicillin shot"; and then you say, "You don't understand, penicillin won't help in that case," and then she says, "What kind of a doctor are you? If you don't want to do it I'll go somewhere eke." '
The biomedical model today is much more than a model. Among the medical profession it has acquired the status of a dogma, and for the general public it is inextricably linked to the common cultural belief system. To go beyond it will require nothing less than a profound cultural revolution. And such a revolution is necessary if we want to improve, or even maintain, our health. The shortcomings of our current health care system - in terms of health costs, effectiveness, and fulfillment of human needs - are becoming more and more conspicuous and are increasingly recognized as stemming from the restrictive nature of the conceptual model on which it is based. The biomedical approach to health will still be extremely useful, ^ust as the Cartesian-Newtonian framework remains useful in many areas of classical science, as long as its limitations are recognized. Medical scientists will need to realize that the reductionist analysis of the body-machine cannot provide them with a complete understanding of human problems. Biomedical research will have to be integrated into a broader system of health care in which the manifestations of all human illness are seen as resulting from the interplay of mind, body, and environment, and are studied and treated accordingly.
To adopt such a holistic and ecological concept of health, in theory and in practice, will require not only a radical conceptual shift in medical science but also a major public reeducation. Many people obstinately adhere to the biomedical model because they are afraid to have their life styles examined and to be confronted with their unhealthy behavior. Rather than face such an embarrassing and often painful situation, they insist on delegating all responsibility for their health to the doctor and the drugs. Furthermore, as a society we tend to use medical diagnosis as a cover-up of social problems. We prefer to talk about our children's 'hyperactivity' or 'learning disability,^ rather than examine the inadequacy of our schools; we prefer to be told that we suffer from ^hypertension' rather than change our overcom peri live business world; we accept ever increasing rates of cancer rather than investigate how the chemical industry poisons our food to increase its profits. These health problems go far beyond the concerns of the medical profession, but they are brought into focus, inevitably, as soon as we seriously try to go beyond current medical care. Transcending the biomedical model will be possible only if we are willing to change other things as well; it will be linked, ultimately, to the entire social and cultural transformation.