The theme in this module and next involves dichotomies.

A dichotomy is a division or
contrast between two things. An example would be “day” versus “night”. Dichotomies are
visible here and in the next module when we talk about health. See if you can spot some.

Sickness, illness, and disease

In our culture we often use the words “sickness”, “illness” and “disease” interchangeably but
there are differences.

This image illustrates the dynamic relationship between disease, sickness and illness

Brown and Barrett (2010:5) elaborate on these definitions. They state that “Sickness is an
inclusive term that includes all unwanted variations in the physical, social and
psychological dimensions of health”. These unwanted variations may include any part of the
body, mind, experience or relationships.

Sickness can be divided into disease and illness. Disease is the outward, clinical manifestation
of altered physical function, it is a clinical phenomenon defined by pathophysiology of
certain tissues within the human organism. It is something that is measurable and explains
why physicians are interested in performing tests. An example would be a test for strep bacteria
and then the diagnosis of strep throat and subsequent prescription of antibiotics.
Illness encompasses the human experience and perceptions of alterations in health as
informed by broader social and cultural dimensions. In this way, part of the illness is the
patient’s difficulty in talking, or not feeling like themselves. Where disease is considered to be
biological, illness includes psychological and social dimensions (Brown and Barrett, 2010).

These two terms illustrate the difference between the patient perspective versus that of the
clinician (doctor). It helps to explain the quality of communication between patients and healers
e.g. a physician may be using a disease model and see the patient’s symptoms as an expression of
clinical pathology, a mechanical alteration in bodily process that can be “fixed” by a prescription.
From the patient’s perspective, an illness experience may be social as well as physiological.
Being ill prevents the patient from working for instance. The perspectives of the doctor and the
patient also play into understandings of what causes illness and disease (explanatory models) and
what is an appropriate cure. The doctor’s diagnosis may not make sense in terms of the patient’s
theory of illness and the “cure” may ignore aspects of the patient’s family dynamics, potential for
social stigma, lack of adequate resources to make follow-up visits or afford care (Brown and
Barrett, 2010).

An explanatory model is a personal interpretation of the etiology (cause), treatment, and

outcome of sickness and it is the mechanism by which a person gives meaning to his or her
condition (Brown and Barrett, 2010). Although they are personal, explanatory models also
contain learned cultural models and an explanatory model shared by a group can be considered a
folk model of disease.

According to Helman (1981), when faced with an episode of ill-health, the person tries to explain
what has happened, why it has happened, and what they should do about it. Think about the last
time that you were unwell. Did you ask yourself these questions? The shaping of the illness and
the behaviour of the individual and of those around them will depend on the answers to six
questions. How the questions are answered and the behaviour that follows constitutes the folk
model of illness.

1. What has happened?

2. Why has it happened?
3. Why to me?
 4. Why now?
5. What would happen if nothing was done about it?
6. What should I do about it or whom should I consult for further help?

These models exist in all cultures and comprise health belief systems. Generally, health belief
systems fall into two categories (Brown and Barrett, 2010):

1. Personalistic belief systems explain sickness as a result of supernatural forces

directed at a patient (for example by a sorcerer or an angry spirit). Healers must use
supernatural means to understand what is wrong with their patients and return them to
health (O’Neil, 2006). Your textbook calls this ‘supernatural causation’ and further
breaks it down into three subcategories.

O’Neil (2006) describes the typical causes of illness in personalistic medical system which
include:

 Intrusion of foreign objects into the body by supernatural means

 Spirit possession, soul loss or damage
 Bewitching
2. Naturalistic belief systems explain sickness in terms of natural forces such as germ
theory of contagion in Western biomedicine or the imbalance of humours in many
Chinese, Indian and Mediterranean systems.

O’Neil (2006) describes the typical causes of illness in naturalistic medical system which
include:

 Organic breakdown or deterioration (e.g. tooth decay, heart failure, senility)

 Obstruction (e.g. kidney stones, arterial blockage)
 Injury (e.g. broken bones, bullet wounds)
 Imbalance (e.g. too much or too little of specific hormones or salts in the blood)
 Malnutrition (e.g. too much or too little food, proteins, vitamins or minerals)
 Parasites (e.g. bacteria, viruses, worms)
O’Neil (2006) states that it is easy for those who only accept a naturalistic explanation to reject
the concept of the intrusion of foreign objects into the body by supernatural means. However,
although at first glance they seem at odds, these two explanatory models have some similarities.
Both naturalistic and personalistic explanations require the belief in something that cannot
be seen, which means that both systems involve an act of faith. Think about germ theory, an
idea readily accepted by most people in the Western world today. It is useful to remember that
during the late 19th and early 20th centuries, microbiologists and physicians had tremendous
difficulty convincing the medical profession that bacteria and other microorganisms were
responsibly for infection and disease. Moreover, it took even longer for the general public in
Europe and North America to be convinced that there are harmful microscopic “germs” (O’Neil,
2006).

There is often disparity and disconnection between the explanatory models of the patient and the
healer. What kinds of problems could this lead to? An example is seen in the book The Spirit
Catches You and You Fall Down, where Lia Lee and her parents, who live in California and are
members of the Hmong population, a group of immigrants from Laos. Lia has seizures and is
diagnosed with epilepsy by the biomedical American doctors. Lia's parents view the cause of her
seizures and their treatment differently. Look up a summary of this book (or read it for fun!) and
learn more about the culture clash of medical systems.

The sick role

What do we do when we are sick? How do we behave? What are the expectations? All medical
systems have a cognitive aspect (see above related to causation) as well as a behavioural aspect.
Parsons (1951) identified the ‘sick role’, which focuses on the social expectations for the
behaviours, including rights and responsibilities, of a person diagnosed as sick. Note the
importance of a diagnosis to lend legitimacy to the patient (think sick note).

According to Crinson (2007)/Martino (2017)

 The rights include exemption from normal responsibilities, e.g. work, household or
caring duties, and not being blamed for their illness;
  The responsibilities include a duty to want to recover, and to seek (and comply with)
medical assistance.

It is accepted that this is a temporary condition; the person is expected to make a full recovery
and return to their regular role in society. The cultural script of the sick role is modelled after
infectious disease, and it fits well with acute diseases, such as a cold or the flu.

But what happens if a person is in a sick role for too long? There are considerable limitations to
the application of the sick role to chronic illness.

3. Firstly, the sick role model assumes that there will always be recovery from illness, which
does not apply to chronic conditions, and it also overlooks the fact that exemption from
‘normal’ duties is not always necessary because many people with chronic conditions
continue to function (e.g. type 2 diabetes).
4. Secondly, it represents a very limited doctor-patient relationship because it relegates
patients to a passive role and doctors to a proactive role, and implies medical assistance is
always sought after and viewed as helpful.
5. Lastly, it encourages patient blaming for their health conditions, particularly where there
is a lifestyle component (e.g. smoking or obesity) (Crinson, 2007/Martino, 2017).

Beliefs

Belief plays heavily in understanding many aspects of health and healing - belief in what is
causing the disease, belief in the medical system itself, and the belief in the power to be healed.
Hahn and Kleinman (1983:3) even went as far as saying “Belief kills; belief heals”. These are
two ends of the spectrum from what they call pathogenic to therapeutic, or nocebo to placebo.
Both placebo and nocebo are powerful. In randomized controlled studies, placebo effect can
account for up to one third of the effectiveness of medical interventions.

Nocebo effect is the opposite – just as our beliefs and expectations can heal us, they can also
sicken and even kill us (Hahn and Kleinman, 1983). Defined by Hahn (1997:607) “nocebo
effect is the causation of sickness (or death) by expectations of sickness (or death) and by
associated emotional states”. “Voodoo death”, where a shaman or medicine man declares a
person will die and then they subsequently wither and die, is an example of nocebo effect.
In 1942, American physiologist Walter Cannon wrote about the potentially fatal consequences of
intense beliefs. Reports of “voodoo” death came in from different groups: South American
Tupinamba men, condemned by medicine men, died of fright; Hausa people in Niger withered
away after being told they were bewitched; Aboriginal tribesmen in Australia, upon seeing an
enemy pointing a hexed bone at them, went into convulsions and passed away. “Voodoo” death,
according to Cannon, was very real (Chen, 2017).

But why does this happen? Basically speaking, it seems that the expectation of negative
consequences results in the manifestation of those negative consequences. Along with “voodoo
death”, the occurrence of epidemic hysteria in schools and workplaces also illustrates the effects
of suggestion and emotional contagion (Chen, 2017).