The improvement in population health is due more to socioeconomical and cultural development and lifestyle improvements than scientific discoveries (as stated in a World Health Organization report). We are more resistant and physically less prone to attack than our ancestors due not to what we do when we are ill, but because we get sick less often, and this is not due to a specific treatment or therapy, but simply because we live in a more wholesome environment.
However, modern medicine would appear to be concentrating its efforts on the aspects related to the diagnosis and pathogenesis of illnesses, overlooking the fact that it is the action of the cultural changes of the environment that is its greatest resource.
Back in the 19th century, Rudolph Virkow, one of the great minds of modern medicine, wrote “Epidemics are caused by disorders of human culture”. We need to re-explore the anthropology of medicine as “it is to do with the nature and destiny of human beings, and not with machines and animals”, as was more recently reported by Dietrich von Engelhardt, LUIMO Forum 2000). There is a need for both scientific and humanistic knowledge, because health and illness are closely related to the physical, social, psychological and ethical nature of human beings.
It is a return to the origins, when Greek medicine defined health and disease in a cosmological and anthropological sense, seeking not merely to treat the disease, but also to maintain health, and the concept of health and disease had profound philosophical implications, and although Hippocrates is considered to be he who separated medicine from philosophy, the model of health that is recognised in the Corpus Hippocraticum is that developed by the pre-Socratic philosophers, who were also the physicians of the time.
is that developed by the pre-Socratic philosophers, who were also the physicians of the time. In the Hippocratic patient-physician alliance, the patient is he who helps the physician to fight disease and the physician is he who is at the service of the patient. With Semeiotics (σημεῖον, sign, τέχνη, “art”) man began to investigate his body, to look for signs regarding the function of organs and systems in normal and, above all, in pathological conditions. It is the first concrete act of medicine as a science, which finds in the school of Kos (the Greek island where Hippocrates worked) its consecration: the switch to the direct observation of the patient. Physicians are men, and their work does not have any supernatural, mystical or abstract aspects.
In “Nature of Man” Hippocrates illustrates the famous theory of the four humours (blood, yellow bile, black bile and phlegm), linking them to the elements (water, fire, earth and air), temperaments, qualities, seasons and ages of life, as well as the main moments of the day.
And the interest for man is so great that it is not misled by common wisdom: one famous example being the examination of Democritus of Abdera, who was considered mad by his fellow townsmen, because he laughed at everything, and who Hippocrates believed, on the other hand, to be the wisest of men, because he was capable of laughing at their madness.
In Plato and Aristotle, the relationship with the patient becomes the factor that characterises the type of physician: the slave’s physician who imposes and the free physician who converses
“The slave physician… prescribes what mere experience suggests, as if he had exact knowledge, like a tyrant, … But the other doctor, who … enters into discourse with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe for him until he has first convinced him … when he has brought the patient more and more under his persuasive influences” (Plato, Leges 48)
Both become models for a bad and good legislator, respectively, in the ideal city of MAGNESIA
Illness as a loss of harmony, a failure in the relationship between body and soul.
However, in the 5th century B.C., the physician and philosopher Alcmaeon of Croton used a political metaphor to describe health: health being like democracy (more specifically, Alcmaeon talks of “isonomia”, equality of laws), and sickness being like a monarchy. As the body achieves health when there is a balance between the organs, in politics there is democracy when all parties are equal and can have their say. Alcmaeon was the first to consider the brain man’s most important organ: indeed, the capacity to process our sensations and thoughts, as well as to organise and give a cognitive meaning to sensory data resides in the brain, and this is why Alcmaeon is considered by some to be the father of psychology.
The connection between body and mind remains close also in the Roman world: “mens sana in corpore sano” is the motto of Juvenal, in which mens has a broader meaning than mere cognitive functions. The concept of disease as the alteration of an equilibrium persists: in the 1st century AD, the great physician Galen returns to Hippocrates’ theory of the humours.
With the advent of the monotheistic religions (Christianity, Judaism and Islam) health is considered the result of a good relationship with God; we lose the ancient Greco-Roman interaction between health, beauty and ethics, which allowed Plato to accept euthanasia for cripples: everyone has a right to treatment; and thus the first public places of treatment were born.
Disease and the suffering that accompanies it becomes a means by which the salvation of the soul and love of God are realised. Disease and pain had four forms: inherited sin, personal guilt, demonic possession and divine proof. Therapy does not so much involve medicines as Dietetics, which does not regard food alone, rather it is a cultural system that includes the way in which man relates to the environment, food and drink, sleep and waking, movement and rest; rules are drawn up, the most famous being those included in the Regimen Sanitatis of the School of Salerno.
It is with the Renaissance that man once again becomes central and medicine loses its sacred component: the experimental model, the relationship between anatomy and function and rational therapy result in an increasingly mechanistic concept of disease.
It is the era in which the great errors are corrected (Harvey introduces the circulation of blood concept, the Copernican revolution affirms the heliocentric theory). But it is also the era of the great epidemics: the plague, smallpox, syphilis. In these circumstances, the physician’s role is not only to protect against infection, but also to keep evil spirits at bay.
According to Descartes, man differs from animals in that he is a combination of body (res extensa) and spirit, thought (res cogitans), differs from res cogitans (spirit, thought): Res extensa operates in accordance with the same physical laws as machines and as such must be studied under conditions of normality and illness; the relationship between these two parts is implemented through the pineal gland located in the centre of the brain: by means of this gland, particles of matter carried by the nerves (spirits) were thought to make the soul feel the movements of the body and stimulate within it the corresponding sensations; the soul, in turn, again through the pineal gland, was thought to set the spirits in motion by acting on the body. The same concept persists today if we think of the action of the neurotransmitters, or areas of the brain (limbic system, hypothalamus, pituitary gland) that are considered the structures that connect cognitive and behavioural phenomena and somatic processes.
However, philosophy, theology and the arts remind us that health, like illness, cannot be attributed solely to physical and objective rules, rather they have a subjective, psychological, social and cultural component. This different concept of health and sickness continued in alternating phases with philosophers like Montaigne, Rousseau and Leibniz, who re-propose the role of individual behaviour and the responsibility of development and the state as the cause of disease, thereby paving the way for the advent of social medicine by Bernardino Ramazzini.
Conceiving man as a set of organs and functions undoubtedly favoured scientific knowledge and technological development for much of the last century; however, it was to the detriment of the body-mind unit and, by giving little importance to psychological and social factors in the aetiology, natural history and prognosis of disease, it restricted therapeutic results. Excessive use of laboratory and instrumental diagnostics have depersonalised the patient, making a number or an image the aspect of greatest interest.
The epidemiology of disease has changed dramatically over the past 70 years, firstly in the so-called industrialised world, and subsequently in the so-called globalised world. Whereas until the first half of the last century infectious diseases were the major cause of morbidity and mortality, and clinical history, due to the poor and ineffective therapeutic baggage, was often exhausted within rather short timeframes, from the 1950s onwards, degenerative diseases and cancer have occupied the top positions in epidemiological investigations.
These are long-term medical conditions with which the patient must learn to live and that significantly impact quality of life; the duration of the disease means that the contact with the world of healthcare becomes more intense and constant, and involves a greater number of practitioners: in English, in addition to “disease” (the objective, physical and medical concept of sickness) we also talk about “illness” (the subjective and more personal aspect of the condition). Therapeutic success is no longer defined by the cure, but by the contribution to “wellness”, and in this setting the intervention of the psychologist, rather than of psychology tout court, takes on an important complementary role.
– Stress, personality traits, anxiety and anger are risk factors for the development of chronic, degenerative cardiovascular diseases; or are a trigger for acute ischaemic or electrical events (heartbreak, tako-tsubo syndrome, sudden death); the way in which they contribute to distant prognosis (depression) or impact treatment compliance (transplant patients, ICD wearers), determine the quality of life of subjects with congenital heart disease. However, it is essential for a psychologist to be familiar with the clinical characteristics of each group of diseases, as the needs, anxieties, expectations and worries of a cancer patient are different from those of a person with heart disease. Not a counselling psychologist who deals out pearls of wisdom, but a specialist who is present and works in the same place as the physician with whom he/she must establish the most effective treatment options, which, in some cases, may be non-intervention: a psychologist who contributes to the realisation of “medical humanities”.
The formulation of this new vision of health cannot ignore the fact that the situation is changing, in our lifestyles, the way we communicate, in the presence of different cultures that follow mass migration. If, in addition to “lived experiences”, diseases are also fundamentally “cultural constructs” that vary greatly from one human group to another, we need to know the specific characteristics of cultures that have come to interfere with our habitat in terms of the way we conceive life, health, disease and death; as suggested by Gualtiero Harrison, an intercultural health policy scholar, we must contribute to the development of medical anthropology, which results in the sharing of a vision of health, in which our technicism is mitigated by a humanity consisting in ethnic histories, tradition, and a different concept of wellness.
The separation between knowledge and medical activities and daily life has fuelled suspicions, mistrust and a lack of faith in official healthcare practices that have persisted through the centuries to the current day, suffice to think of the anti-vax movement or the refusal to have chemotherapy in favour of alternative treatments with no scientific construct. Easy access to the often unfiltered information that can be obtained from the Internet favours a kind of DIY medicine and is detrimental to the patient-doctor relationship; increasingly, patients seek people like themselves, often forming associations, in order to share experiences and treatments; this is an archaic approach, as Herodotus narrated in his tales “the Babylonians take the sick to the market, because they do not have doctors… people then go to the sick man and give him advice regarding his sickness: if someone has suffered from something similar to the sick man’s ailment, or has seen someone with the same disease they approach the sick man and give advice and instructions on the means that freed them of a similar illness or that they have seen free others.”
Prof. Luciano Daliento
Former Professor of Cardiology
Senior Scholar Università di Padova