Making Sense of Illness is a fascinating investigation into the social and clinical factors that determine what constitutes a "legitimate" illness in the twentieth century. By examining six case studies of diseases that have emerged within the past fifty years--from what we now consider to be "straightforward" diseases such as coronary heart disease, to the currently widely-debated Chronic Fatigue Syndrome--Aronowitz examines the historical and cultural factors that influence how doctors think about illness; how illnesses are recognized, named, classified, and finally, what they "mean" in an individual and social context. The choices that are available to the investigators, clinicians, patients and the processes by which change occurs are factors that all play a great role in "legitimizing" an illness, and these are the roles that are seldom examined. By juxtaposing the histories of each disease, Aronowitz shows how cultural and historical precedents have determined research programs, public health activities, clinical decisions, and even the patient's experience of illness. This is a must-read for anyone interested in public health and the history of medicine in the United States.
Dr. Aronowitz champions the holistic approach to the care of patients in the face of what he sees as the current science-oriented, reductionist approach to the practice of medicine. For example, he believes that in the past, the creation of new disease categories was the outcome of a largely "social process of negotiation" to which clinical and laboratory expertise contributed but in which they were not preeminent, as they are in the contemporary setting. Aronowitz suggests that by understanding the process by which disease categories are created, we are in a better position to assess all aspects of a disease, its effect on individuals and society as a whole, and the reaction of patients, society, and the health care system to the disease itself. He points out that the focused, disease-specific, scientific (ontologic) view gained ascendancy with the germ theory in the latter part of the 19th century and led to the credo of contemporary molecular biology: one gene, one protein, one disease. The result, he fears, has been a loss of appreciation of the influence of individual characteristics, including emotions, lifestyle, and social class.
However, the picture is not entirely bleak, because of a further development in medical thinking during the past 20 years. This the author terms the "risk-factor approach," which forms a bridge between the seemingly competing ontologic and holistic ideologies. The risk-factor approach combines the rigor of scientific identification of specific disease risk factors with the creation of a profile of the individual patient. That profile is as unique to the patient as risk-factor science is specific and has major implications for preventive medicine. Notwithstanding some of the author's reservations, this theme is well developed in the book and owes much to the discussions with Dr. William Kannel, who, with his colleagues in the Framingham Study, originally coined the term "factors of risk" in the early 1960s.
The book explores the concept of the "social construction of disease" and the factors that have a role. These factors are illustrated by the discussion of five cases in the introduction and again in the conclusion and explored under chapter headings covering the psychosomatic hypothesis of ulcerative colitis, the history of chronic fatigue syndromes, Lyme disease, the changing interpretation of angina pectoris, the development of risk-factor thinking, and the type A hypothesis.
The book is well referenced, and important quotations have been inserted -- for example, on thinking about angina by William Heberden, William Osler, Thomas Lewis, and Paul White; on the importance of diet by Ancel Keys and others; and on the risk-factor approach by William Kannel, William Castelli, and more recent experts. The extensive quotations add greatly to the appeal and clarity of the overall work.
This book will stimulate responses from both the ontologic and holistic camps. No doubt, the ontologically inclined will in the end still question whether one has to treat the "whole person" if one can rid him or her speedily and painlessly of disease and hence prevent the necessity of a long-term "association" with the medical professional. The holistic advocate will still say that no disease is that simple to treat and that much of the research undertaken is so far removed from having clinical application that its chance of leading to therapeutic innovation often borders on the fortuitous.
We are told that Dr. Charles Rosenberg, as series editor at Cambridge University Press, continually challenged the author to be more precise and brief. The failure of the book to reflect this advice fully may act as a barrier to readers whose attention spans flag toward the end of long sentences (sometimes 60 words or more with subordinate clauses). I suspect that few will want to read this book all at once but that many will enjoy keeping it at hand and picking it up from time to time to browse. It should be especially appreciated by the new breed of academics incessantly involved in designing and redesigning the medical school curriculum. Through them the book stands a chance of having an impact on the practice of medicine in the future, especially if it convinces educators that, rather than packing the curriculum with all the new knowledge available, they could provide students with "unstructured" private time, time to think, and possibly even a little time to chat with patients as human beings.
Reviewed by David J.A. Jenkins, M.D., Ph.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
