Diseases of Modern Life Flashcards
Timmerman (2011), emergence of chronic disease as a category
20th C, first in USA and later elsewhere in industrialized world
Post-war:
term ‘chronic’ was increasingly used as a synonym for ‘non-communicable’
acute phases of these ‘new’ chronic diseases were thought to be preceded by long, symptom-free periods, even dormancy, and triggered by various forms of stress—not unlike consumption in the early nineteenth century.
it may have been the
shortage of adequate facilities for patients with long-term illnesses in the USA (compared with the relative abundance of pauper beds in Britain and France, for example) that prompted the emergence of chronic disease as a new, distinct category
Kleinman, distinction between ‘illness’ and ‘disease’
‘illness’ = the experience
‘disease’ = an identifiable entity
Timmerman (2011), past experiences mimicking those of ppl with chronic disease in the 20th-C
sufferers from tuberculosis or syphilis, for example, once
touched by the illness, were cursed for the rest of their lives: the illness and its symptoms, abating and recurring, good days and bad days, came to define their biographies—a feature that recent analysts have described as characteristic of the modern chronic illness
experience
Illich, origins of chronic diseases (Timmerman’s Account)
characterized
chronic disease as an effect of civilization, caused by alienating aspects of modern life that
disturbed the age-old harmony of man and nature and by the failures of recent medicine.
Timmerman (2011), consumption’s persistence, summary
While it is often assumed that tuberculosis and consumption were identical, consumption, I argue, did not disappear when tuberculosis was conquered
some of consumption’s cultural meanings transferred to other chronic illnesses in the twentieth century.
René and Jean Dobos, The White Plague
much of what was described as consumption in old
medical writings was not pulmonary tuberculosis.
Until the late nineteenth century, when a patient was seen to waste away slowly and seemingly inevitably, the diagnosis was usually consumption.
Timmerman (2011), consumption
Rather than being synonymous with tuberculosis—a diagnosis that presupposes the identification of tuberculous lesions in post-mortem examinations and,
following Robert Koch (1843–1910), the demonstrable presence of a specific bacillus— consumption was associated with the clinical picture of patients deteriorating, sometimes rapidly, sometimes over years.
Wasting diseases whose final stages were often characterized as consumption included also scurvy, scrofula, and various forms of cancer.
Conditions such as asthma or dropsy were also linked to consumption
Consumption, thus, was not a distinct disease entity, but rather, being consumptive was a personal quality
Once consumptive, incurable.
Chronic illness signalled a
weak constitution irreparably damaged by a life lived carelessly or under unfavourable conditions.
Consumption was thus the endpoint of much chronic illness
pulmonary tuberculosis remained a chronic, incurable disease until the mid-twentieth century, despite considerable investments.
Timmerman (2011), perceived causes of consumption
If an individual had a consumptive diathesis, that is, an inherited
proneness to consumption, the illness could be brought on by a variety of precipitating factors.
Overindulgence, for example, might merely lead to a salutary attack
of gout in an individual with a strong constitution, clearing the blood of purulent matter. In
individuals with a weak constitution, be this due to poor inheritance, previous illnesses, or
bad habits, the same behaviour might trigger consumption.
Timmerman (2011), importance of patient stories
they complement longue durée histories of disease that focus merely on statistical patterns. They tell us what illness meant for individuals and also
illustrate the role of individual patients in a historiography of medical progress that has
traditionally been written exclusively around contributions by medical researchers.
Sanitary Commission for Investigating the State of the Infirmaries of Workhouses for The Lancet in 1865
Multitudes of sufferers from chronic diseases, chiefly those of premature old age, crowd the so-called
‘infirm’ wards of the houses, and swell the mortality which is a melancholy characteristic of these establishments. Examples are not uncommon in which the really able-bodied form but a fourth, a sixth, or even an eighth of the total number of inmates.
Timmerman (2011), shift in process of diagnosing consumption
What defined the disease in the classificatory system promoted by Laennec
and his followers was no longer a (potentially infinite) set of symptoms that the physician considered in the context of the patient’s biography, but the existence of a finite number of specific disease markers in the body
Peitzman (Timmerman’s account)
diagnosis of Bright’s disease in a person with no symptoms, based merely on a urine examination, ‘represented an entirely new manner of transforming a person into a patient … The felt bodily sensations of the patient and the patient’s recounted story of them, would increasingly lose their primacy and power
Timmerman (2011), Diabetes mellitus
Matthew Dobson (d.1784), a Liverpool physician, suggested that the sugar was not formed in the kidneys but removed from the patients' blood, explaining their emaciation. A succession of dietary therapies followed, which attempted to feed sufferers with foods their bodies could assimilate, but with minimal benefits
Children under ten years of age could expect to live no more than three years following diagnosis, while elderly patients survived for about twice as long.
diabetes became model for the long-term management of other conditions being identified as chronic diseases. When the
British clinician Smirk experimented with the clinical use of the ganglion-blocking drug hexamethonium for the treatment of malignant
hypertension in the early 1950s, he implemented a similar regime, instructing patients to self-inject the drug with tuberculin
syringes
Isolation of peptide hormone by Banting, Best et al
1921
First British insulin available
1923
Patients’ had to have own regime of self-injection - power back to them from clinicians?
Timmermans (2011), renal failure
identity of renal failure was similarly transformed when, from the 1960s, dialysis was increasingly available to chronic renal patients. These new regimes required a high degree of organization and self-discipline.
Timmerman (2011), antibiotics and drug companies
Antibiotics since the 1940s cured many chronic infections and shortened hospital stays.
Following the antibiotic bonanza, drug companies proved keen to develop the market for cardiovascular
drugs and other treatments for chronic illness, which promised stable and long-lasting profits.
Timmerman (2011), TB and welfare
1911 National Insurance Act was partly motivated by concerns over tuberculosis. The Medical Research Council had its roots in this context: its precursor institution, the Medical Research Committee, was established to promote research into this disease. Many of the new welfare services in the interwar period were dedicated (besides mother and child provisions) to tuberculosis,
Timmerman (2011), changing mortality and morbidity patterns and their significance
Deaths in childhood/adolescence had declined rapidly
more people lived past
middle age, making illnesses associated predominantly with middle and old age, such as heart disease, strokes, or cancer, much more visible
By 1950s, mortality rates for TB lower than cancer
lung cancer sole contributor to increase in cancer deaths: work by R. Doll (1912-2005) and A. B. Hill (1897-1991)
rise of welfare administrations and the growing costs associated with this development turned the prevention of these conditions into an important issue for public health policy.
Graph of the 1962 Report by the Royal College of Physicians on Smoking and Health (Timmerman, 2011)
mortality from a number of respiratory diseases among men aged 45 to 64
around 1950, for the first time, mortality from tuberculosis in this cohort was lower than that from cancer
Also, lung cancer alone was to blame for the increase in cancer mortality, a disease that by the mid-1950s had been firmly linked to smoking cigarettes
US National Health Survey 1935-6
over 700,000 households in 83 cities
nearly 1/5 of population had a chronic disease or disability
Joint Comte on Chronic Illness formed
1945
by the American Hospital Association, the American Medical Association, the American Public Health Organization, and the
American Public Welfare Association.
Committee passed on the baton in 1949 to a Commission on Chronic Illness, which published four-volume report in 1957.
Welfare Council of New York study, 1928
20,700 people incapacitated by chronic conditions
Only one-fifth of these (403) were over 70 years old; more than half were under 45.
NY Welfare Council estab comte on Chronic Illness
1933
chaired by Boas
With its ageing population, Boas argued, America was facing a social and health crisis to which a public health system focusing on mortality alone could not do justice
Journal of Chronic Diseases launched
1955
Timmerman (2011), shift in US approach to chronic disease post-WW2
in Cold War context, shift away from social factors to clinical parameters
Heart disease and cancer were increasingly associated with affluence,
public health interventions were aimed at educating people individually to reduce their personal risks of developing health problems later in life
Post-War chronic disease in Britain (Timmerman 2011)
urvey commissioned by the Ministry of Health in 1954 focused on the provision of services, finding that the majority of chronic sick beds were in former municipal and Poor Law hospitals
much of the accommodation was unsuitable, in damp buildings with narrow staircases and without lifts, with insufficient bathrooms and dayrooms, and poor heating and lighting. All was still distinctly reminiscent of the workhouse. As in America, patients in these institutions were increasingly medicalized
However, in Britain this led to the development of geriatrics as a specialty
editorial in the Journal of the American Medical Association
we find ourselves in the fifth phase of an epidemiologic transition: the ‘age of obesity and inactivity’
Timmerman (2011), critique of Omran
Omran’s article suggesting epidemiologic transitions has contributed to the misguided notion that chronic disease has only become a problem in the twentieth century
In order to arrive at a more nuanced picture of such continuities and change,
we need more histories that contrast and challenge the statistics-driven master narrative behind the theory of epidemiologic transition
Timmerman (2011), similarities between chronic diseases of the 20th/21st C’s and those of the 19th C and earlier
chronic illness in the early twenty-first century is still linked to individual biographies and constitutions, and blamed on behaviours associated with civilization
Jones et al. (2003), PTSD, methodology
Using historical medical files of soldiers who served in the Boer War and in the First and Second World Wars, we have attempted to test the hypothesis that the symptom clustering associated with PTSD existed before psychiatrists recognised it as a formal disorder
Testing in partic, incidence of flashbacks - largely limited to PTSD as diagnostic tool
1856 cases were included (Table 1), drawn from seven conflicts and representing ten diagnoses
Previous historical investigations have relied on single case studies to make the point that PTSD is a timeless disorder
However, such studies lack a denominator and are instead based on an active search through historical literature for descriptions that resemble modern formulations of PTSD, while presumably discarding presentations that appear different.
Dean (1997), PTSD
symptoms of PTSD, including flashbacks, can be identified in the accounts of veterans of the American Civil War
Trimble (1985), PTSD
‘this relatively common human problem has been known for many hundreds of years, although under different names’
Young, PTSD
PTSD is a culture-derived diagnosis and can only have existed in the late 20th century
Mumford’s analysis of the Iliad
showed that the heart alone (and not the head or the abdominal organs) was associated with emotional distress
In the Hebrew Bible too, he found that the heart was interpreted as the seat of the emotions, will and intellect
significantly different somatic vocabulary from that of today and the one reflected by PTSD.
First Diagnostic checklist for PTSD published in DSM-III in 1980
- flashbacks - ‘Re-experiencing of the trauma’. Recurrent recollections, dreams, feeling as if trauma reocurring. 1987, DSM-III-R included ‘flashback’ as synonym for some aspects of these experiences
First Diagnostic checklist for PTSD published in DSM-III in 1980
- intrusive symptoms (such as nightmares, flashbacks and persistent memories) (1987, DSM-III-R included ‘flashback’ as synonym for some aspects of these experiences)
- avoidance symptoms (such as emotional numbing, withdrawal from the world and avoidance of reminders)
- symptoms of overarousal (such as insomnia and irritability)
Jones et al. (2003), PTSD, conclusions
Analysis of the 1856 cases revealed that flashbacks, symptoms of intrusion and avoidance, were virtually non-existent before the First World War and were still rare during the Second World War
Although not a common phenomenon today, their incidence is significantly higher than in previous conflicts
Somatic symptoms appear much more often in presentations of post-trauma illness from the 19th and early 20th centuries - somatic descriptions = poss explanation for rarity of flashbacks WW1 and 2
Shellshock, for example, was often depicted by contemporaries in terms of contractures, tics, movement disorders and paresis
psychopathology of trauma is not static and that culture has an impact on the expression of distressing memories
PTSD is one more phase in the continually evolving picture of human reaction to adversity
Reasons for rise of the flashback
- Shorter - nature of medically unexplained syndromes has itself changed, with a shift from apparently neurological symptoms such as paralyses, tremors and fits to more ill-defined and subjective symptoms such as fatigue, pain and depression
- Blank - direct association between the flashback and films/ rise of cinema
- Yet films were an integral part of popular culture during the First and Second World Wars, when flashbacks appear to have been much rarer than today. Involuntary visual images may be tied more closely to the mass production of affordable television sets in the 1950s and 1960s and the subsequent introduction of video recorders. supported by the intrusive nature of the flashback. People make a conscious choice to go to the cinema. television in the home can be a source of sudden and disturbing imagery in a familiar and apparently safe situation.
Petrie, Wessely (BMJ, 2002), mistrust of modernity
Over recent years there has been a steady and important change in the public’s perception of the relation between aspects of modern life and health. Now, at the beginning of the 21st century, people’s suspicion of modernity has increased to such an extent that it has undermined their view of their own health, increased their worries about environmental causes of poor health, and fostered a migration to complementary medicine
Petrie, Wessley (2002), medical significance of general mistrust of modernity
This anxiety is reflected in the pattern of presentations of psychosomatic illness: the number of illnesses attributed to environmental factors—for example, sick building syndrome, multiple chemical sensitivity, total allergy syndrome, and 20th century disease—has increased
Bc ppl feel more vulnerable, normal everyday symptoms such as headache and fatigue are now more easily interpreted as signs of disease or ill health.
Petrie, Wessley (2002), reason for unease with modernity
increase in the public’s fascination with personal health and medicine, as evidenced by the burgeoning of gyms and fitness programmes, and the widespread adoption of a “healthy lifestyle.
The media’s increased coverage of health topics, in stories on the dangers lurking in ordinary activities such as air travel and vaccination, has raised worries about routine health care
Well publicised crises, most obviously bovine spongiform encephalopathy and foot and mouth disease, have severely dented confidence
focus of the media on risks with a novelty value fosters the belief that they are far more common than they actually are
the internet - new and unsubstantiated health worries can be instantly transmitted to an internet audience eagerly seeking information on health or to special interest networks, such as illness support groups. A recent US study of hospital outpatients found that 25% of the patients had used the web for medical information in the past year
med scares transmitted on web + via email - antiperspirants causing breast cancer
result of this deluge of information on the supposedly pervasive risks to personal health is that people now feel much more vulnerable.
Petrie, Wessley (2002), reasons for unease with modernity
increase in the public’s fascination with personal health and medicine, as evidenced by the burgeoning of gyms and fitness programmes, and the widespread adoption of a “healthy lifestyle.
The media’s increased coverage of health topics, in stories on the dangers lurking in ordinary activities such as air travel and vaccination, has raised worries about routine health care
Well publicised crises, most obviously bovine spongiform encephalopathy and foot and mouth disease, have severely dented confidence
focus of the media on risks with a novelty value fosters the belief that they are far more common than they actually are
the internet - new and unsubstantiated health worries can be instantly transmitted to an internet audience eagerly seeking information on health or to special interest networks, such as illness support groups. A recent US study of hospital outpatients found that 25% of the patients had used the web for medical information in the past year
med scares transmitted on web + via email - antiperspirants causing breast cancer
result of this deluge of information on the supposedly pervasive risks to personal health is that people now feel much more vulnerable.
Petrie, Wessley (2002), new technologies
The rapid introduction of new technologies has been accompanied by important adverse effects in the way people make sense of illness and present with health complaints.
DSM
Diagnostic and Statistical Manual
of the American Psychiatric Association (PTSD 1st included in DSM III)
Bracken & Petty, 1998
called into question cross-cultural export of PTSD counselling programmes to non-Western communities who have suffered wartime violence
McFarlane, psychoanalysis (Bracken’s account)
McFarlane suggests that the decline of interest in psychoanalysis as an explanatory model has decreased the emphasis on unconscious conflicts in the causation of psychiatric disorders, which in turn has lead to an increasing focus upon life events, and in particular, traumatic life events, as causative factors.
Judith Herman (1992), trauma (Bracken’s account)
there has always been a tendency to push traumatic events, not only out of individual consciousness, but out of social consciousness as well.
discourse on trauma has emerged because of a number of political developments, most importantly the rise of the women’s movement in Europe and North America
The advent of feminism, she suggests, by allowing a recognition and understanding of the effects of rape and other forms of sexual violence, has made it possible for psychiatrists to examine the effects of trauma and to take the victims’ accounts of their suffering seriously.
large-scale social movements which opposed the war in Vietnam allowed for a critical examination of the effects of wartime experiences
PTSD has always existed but has remained almost invisible to psychiatry until recent polit developments
Young, trauma discourse (Bracken’s account)
origins late 19th century when the notion of the ‘traumatic memory’ became popular in medicine
recent discourse on trauma has inherited this concept but has also been substantially shaped by a number of theoretical developments in American psychiatry
the concept of PTSD has been constructed over time; it has a history
PTSD has come to be constructed on account of changes in psychiatry itself - t is part of an effort to secure a scientific basis for psychiatric classification
Bracken (2001), PTSD and culture
concern with psychological trauma is not simply a clinical issue, it would appear that it is also a cultural event
A number of clinicians and researchers have argued that the characteristic intrusive and avoidance symptoms of PTSD can be best understood as evidence of the victim’s search for a new sense of meaning and order in the world in the wake of the traumatic experience.
Cognitive theories have become dominant in this area and most researchers assume that trauma produces its effects by undermining the unconscious models or ‘schemata’ which serve to structure an individual’s reaiity
Horowitz, Stress Response Syndromes (1986)
‘information processing’ model of trauma
A traumatic event presents information which conflicts with pre-existing schemas. There is thus an incongruity which gives rise to distress. This provokes a ‘stress response’ which involves reappraisal of the event and revision of the schemas. If the event is highly traumatic this process is prolonged. However, until such time as the process is complete, the event remains stored in ‘active memory’:
Because the representation of the traumatic event is stored in active memory it is replayed over and over again, each time causing distress for the individual
To prevent emotional exhaustion, inhibition and facilitation processes become involved.
If there is a failure of inhibition, intrusive symptoms such as nightmares and flashbacks occur.
Bracken (2001), cognitivist vs anthropological approaches
cognitivists - psychology and culture are separate realms.
While culture may help shape an individual’s understanding of the world, there are universal psychological processes which make such understanding possible in the first place. It is these that are damaged by trauma
Anthropologists - Kleinman -
very basic aspects of our reality are culturally constructed.
Culture shapes emotions
Jenkins (anthropologist)
need to look at ‘collective trauma’: Because traumatic experience can also be conceptualised collectively, person-centred accounts alone are insufficient to an understanding of traumatic reactions
Summerfield, based on his work as a psychiatrist in Nicaragua
the individualistic concept of PTSD cannot grasp the cultural dimension of suffering in times of war, particularly in non-Western settings
Button (1995)
while rejecting Descartes’ ontological dualism, cognitivism continues to endorse his epistemological separation of inner mind from outside world
Bracken (2001), postmodernity and meaning
contradictions of post-modern society are simply exaggerated tensions which have always existed within modernity. One of the key features of modernity which makes it different to what Giddens refers to as ‘traditional society’, is its extreme dynamism.
In most Western societies there has been a move away from religious and other belief systems which offered individuals stable pathways through life, and meaningful frameworks with which to encounter suffering and death. During the same period the individual self, although more important than ever before, has been undermined by the very forces which assert this importance
For in the post-modern condition the self becomes the source of the meaning of the world while at the same time it becomes disconnected from that world.
Within the cultural horizon of late or postmodernity individuals live their lives without recourse to firm foundations. While this offers unprecedented freedom for individuals to define their own identities, their relationships and their beliefs about the world, it also brings with it a burden of what Giddens calls ‘ontological insecurity’.
Bracken (2001), PTSD and postmodernity
If attempts to reestablish a sense of coherence and order are what lie behind the intrusive and avoidance phenomena codified in the syndrome of PTSD, and these efforts are, to some extent at least, driven by the structures of the surrounding culture, then, we would expect that in cultures which cannot be characterised as modern or post-modern there might well be very different reactions to terrible events
PTSD thus the product not of trauma in itself but of trauma and culture acting together
PTSD is the product of a particular cultural situation. It is a disorder of our times
Giddens, three elements of dynamism of modernity
- separation of time and space
- social and cultural institutions become separate from local contexts and stripped of specific local orientations
- reflexivity
Caplan (1995), Railway spine timeline
- Born in 1866 as exclusively somatic disease
- 1880s - confusing psychical ailment
- 1890s - a state of somatic-psychic flux
- Early death in 1st decade of 20th C
- Contribd to fundamental restructuring of the somatic paradigm and re-legit of psychogenic notions of causality
Name of the condition - railway spine - was indicative of late 19th C med’s materialistic orientation
Caplan (1995), how did railway spine present
Railroad accident, then cases of full or partial paralysis, headaches and various aches and pains oft emerged at later date
wide variety of symptoms:
eg. defective memory ill temper hot head perverted taste and smell sexual impotence
cld only be diagnosed from patient’s symptoms
John Eric Erichsen, Railway spine
1st to describe group of symptoms, mainly nervous, that frequently occurred after a concussion of the spine
Argued by way of analogy and according to clinical observation
Similarity w Beard - sought to apply single label to wide variety of symptoms
Caplan (1995), railway spine and gender
men more likely to be victims since most likely to travel by rail
Presence of apparently hysterical symptoms in men convinced Erichsen that symptoms elicited by railway accidents and other traumas must be indicative of some serious organic disturbance
- Inconceivable that man cld display hysterical symptoms w/o serious organic disturbance
Smith-Rosenberg, sympathy
hysterics typically denied the sympathy granted to sufferers from unquestionably organic ailments
Herbert Page, building on Hodge’s analysis (opponents of Erichsen)
Symptoms emerging at later date cld only be explained by psychical factors
Fright itself = capable of eliciting neuromimetic symptoms by way of some willful hypnotic state
Disappearance of symptoms following financial settlements
Patient shld be freed from hurtful sympathy of friends
This = one of the first exclusively psychological explanations for both cause and cure of functional ailments
Medico-legal controversy
Prior to publication of E’s lectures, accident victim who failed to display clearly discernible anatomical or physiological symptoms not likely to fare well in a court of law
E’s book forever altered this situation
Plaintiff - used Erichsen - organic - injury to spine
Defence - Page - simulation
Role played by juries was source of special irritation to railway surgeons and the corporations they repd - tendency to sympathise w plaintiff
At trial, plaintiffs likely to win almost 70% of cases against railroads, and such findings rarely overturned on appeal
Financial impact of Erichsen’s work
In 1st decade following publication of his book, English railway companies paid more than $11 million in damages
Similar figures cited for the US
Hundreds came from those seeking compensation for spinal concussion, or what an eminent physician soon termed ‘Erichsen’s Disease.’
R D Wallace
Railway spine = merely a symptom of the present ‘epidemic of madness and insane furor against the railroads and othe rcorporate enterprises.’
Response to Growing incidence of alleged cases of spinal concussion and the frequent willingness of juries to find for the plaintiffs
formation of several regional assocs of railway surgeons
First such local assoc was estabd Jan 1882
Over course of the decade more than 50 additional local organizations established
28 June 1888 more than two hundred mems - representing several of these organizations - met in Chicago and founded the National Assoc of Railway Surgeons
Later that yr, the assoc issued the first volume of the Natioanl Assoc of Railway Surgeons Journal
Denied reality of spinal concussion
Outten, chief surgeon for Missouri Pacific Railway
sympathetic attention of friends and loved ones aggravates patient’s condition by fixing his mind on his ailments and suffering
Physicians’ role in creating this condition - when crashes in cities more railway spine cases bc more physicians to say so - 20x more accidents (neurologists partic to blame)
Outten and other American railway surgeons had inadvertently generated a novel synthesis regarding hypothesis and suggestion
Traumatic neuroses, while legit med ailments, were typically the afflictions of the hereditarily tainted and morally suspect
Borrowing from Charcot
Claims railway accidents merely triggered preexisting tendencies.
Their oft dismal plight bore little or no relationship to train wreck - like dry powder in search of a match
Where free of vices, Bernheim’s psychical doctrines more enticing - used to shift blame from accident to attending physician and sympathetic friends, loved ones, lawyers
Punton - failure of enforcement of isolation to be sufficient ground to excuse any railroad company from further responsibility of any claims
American railway surgeons thus unwittingly became first American med specialty to achieve consensus regarding therapeutic value of what wld soon be known as psychotherapy
Caplan (1995), therapeutic signif of railway spine debates?
little
Prior to first decade of 20thC, nervous disorders, regardless of perceived etiology and pathology, were treated in virtually identical manners
Porter (1993), diseases and social groups
Practically all humans live in social groups
All diseases at least trivially = diseases of civilization
Infections e.g. measles need pools of susceptibles to provide continuous chains of hosts in space and time
Fact of history at least until recent times that disease incidence runs in direct ratio to settlement density
Porter (1993), disease and urbanity
17th C rise of ‘new diseases’ - e.g. rickets, assoc by contemps w deleterious facets of urban life
TB widely ident as essentially an urban diseases, esp tragic bc cuts off young in prime
Rural enclaves oft escaped epidemics
19th-C, correlation between disease and the city appeared most inescapable
1852 ‘Great Stink’ from Thames forced adjournment of Parliament
Spread of big city life apparently making pops more vulnerable to new modes of ailment midwived by modernity e.g. hysteria, hypochondria
20th C, great killer infections that had so long decimated urban communities were in rapid retreat
Affluent city came to be recognized as site of the most effective h-c delivery system
It is the First World - urbanized, industrialized, civilized, that enjoys longevity and salubrity at close of 20th-C
Porter (1993), early modern med
Link between societies and sickness made explicit in Early modern med
Charting, containing and curbing town-specific diseases exercised med administrators of early modern Europe
Public-hlth experts in Renaissance Italy promoted and perfected quarantine protocols
Riley, Enlightenment
renewed methods made during Enlightenment to document disease and plot patterns of incidence against natural and social-environmental factors such as climate, waste disposal etc
Porter (1993), rival aetiological thoeries
‘Contagionists’ - indiscriminate bodily contacts towns created
‘Miasmatists’ - e.g. Chadwick, argued the new ‘shock towns’ produced highest concentrations of garbage, rotting refuse, decaying animal, faeces etc, all of which emitted gaseous effluvia, which were disease in own right or at least its bearers
Others emphd moral links - idleness, indigence, ignorance amongst w-c’s bred lifestyles which bred disease. Greeat pop of such arguments on both sides of Atlantic during cholera pandemics 1830s and 1840s
Porter (1993), diseases of civilization as ideological construct - early use
Concept of ‘diseases of civ’, superimposing medical and moral, 1st activated 18th C - serving as secularized revamping of Christian legend of the Fall, wherein Original Sin and expulsion from Paradise had inaugurated the regime of hard labour, disease, suffering and death in the temporal world
Rousseau - ‘primitivist’ - and popularizing physicians e.g. Scot George Cheyne - argued what might be termed ‘noble savages’ and their sturdy hunter-gatherer and peasant descendants, of necessity pursued hlthy life-styles
Devel of town life led to deleterious habits e.g. (590) over-eating, hard drinking
Artificial demands of smart, high-pressure high society and enlightened living amongst literati and glitterati were seen as creating new world of diseases
Porter (1993), diseases of civilization and central nervous system
Cheyne, Tissot and followers -
discarding conventional theories of humoral balance, they emphd that key to hlth and happiness lay in correct nervous tone
Excessive consumption of fine foods and alcohol, and lack of exercise, combined to obstruct the nervous fibres
Notion of diseases of civilization went hand-in-hand w increased explanatory import of the central nervous system
1670s, Thomas Sydenham guessed that about 1/3 of all disorders in Br were ‘nervous’
By 1800, Trotter was suggesting their incidence had doubled
‘nervousness’ cld be taken as symptom of success no less than sickness
Applied to nations as well as individs
Porter (1993), notion of ‘diseases of civ’ in 19th C
19th-c that notion of ‘diseases of civ’ attained greatest credibility and max scare-power
Shift - instead of diseases of civilization and signifying superiority, idea’s dark side became dominant
Partly bc certain disorders that fell under epithet’s umbrella grew more deadly, above all TB, which climaxed around mid-19th C, accounting for up to 1/4 of all urban deaths in north-western Europe and eastern US seaboard, esp those of young adults
Leading TB docs e.g. Beddoes explicitly blamed the menacing curse of the disease upon the effete and aetiolated hot-house life-styles cultivated by the beau monde
Porter (1993), cultural anxieties maturing after 1850
- Growing stress on role of heredity in spreading sickness down generations
- Social Darwinist view that nations and races locked in struggle for survival that would penalize weakness
- W rise of class tensions and social strains in age of industrialization, widespread feeling the social body itself was sick
- fears grew that soc itself being crippled by growing burden of delinquent and maladapted - parasites of the ghetto and its subcultures - degenerationism
Porter (1993), degenerationism
- Originally assoc w Morel
- Socio-cultural traits of modernity were morbidly self-destructive
- US nerve-doc George Beard, career strains in the business rat-race devitalized high-flyers - Cerebral circuits suffered overload
- Widely assumed that the degenerate would breed disproportionately
Lombroso = pioneer of….
anthropometry and psychiatric criminology which employed cranial measurement and photography to identify the diseased sectors of civilization, w view to isolating, treating or even sterilizing criminal and prostitute types, atavists and immoralists
Porter (1993), eugenicism
- direct response to perceived rise of degenerate underclasses
- Immigration restrictions - Aliens Act 1905
- US - several state legislatures promoted programmes of castration and sterilization
- Nazi programme of race hygiene
Freud (Porter 1993)
- complaints commonly presented by patients e.g. depression cld be attribd to psycho-pathology of everyday life in modern, urban, affluent civilization
- Bourgeois respectability and prudishness and delayed marriage took heavy psychological toll
- ‘repression model’ presumed that biologically healthy drives e.g. libido were necessarily suppressed to meet demands of social order
- Resulted in pschological and psychosomatic disorders
Rise of social medicine (Porter 1993)
- 1930s and 40s
- championed in partic by Winternitz at Yale and Ryle at Oxford
- devel of sci med under bacteriology was counterproductively narrow
-Epidemiology had to move
beyond the pathology laboratory and into society as a whole
- Sickness trends = functions of social variables such as class, income, status, occupation
—> what was psycho-socially triggered could not
adequately be treated by pharmaceutical or surgical interventions alone.
- Bc of their research and publicity efforts, became common wisdom that certain sorts of disorders consequential upon deleterious life-styles and environments
Porter (1993), rise in ‘new’ conditions 20th C - optical illusion?
e.g. caused by more precise diagnostic techniques
more intense screening
Porter (1993), qualifications to attempts to dress up old myth of ‘diseases of civilization’ in new garb
- Black Report and other British surveys: heart attacks pre-eminently afflict not social groups one and two but four and five - the poor, deprived, under-educated
- Much in heart disease that has been assoc w category of ‘civilization’ may be attributable specifically to nicotine
- W spread of hlth ed, enlightened eating habits, seems likely that today’s so-called diseases of civilization are not in any straightforward sense the products of affluence, but rather diseases disproportionately afflicting the least privileged mems of advanced socs
- cancers, heart conditions, respiratory diseases etc are rapidly worsening amongst the masses of the Third World, evidently spread by industrial toxins, dietary dislocation, cigarette smotking
- AIDS - for many moralists, the quintessential disease of modern life-styles - has mainly devastated Third World
Porter (1993) - ideological indictment of modern life-styles oft extended to modern med
- Suggested such diseases as cancers have defied sci research and resisted cure precisely bc methods of sci (fixated upon reductionistic, materialist approach to the body, and expectation of specific remedies, a ‘pill for every ill’) are inappropriate for handling systemic and constitutional disorders, from MS to ME, whose aetiology may include an irreducible psycho-somatic component and be personality linked
- Illich: modern med = one of the prime diseases of civilization, not only spreading iatrogenic disorders, but orchestrating a disabling ‘expropriation of health’.
Porter (1993), allure of alternative medicine
lies in its ability to link philosophies of sickness to a wider disaffection w, and critique of, industrial soc, nostalgically evoking myths of golden ages of hlth and seeking a return to Nature
Porter (1993), irony of civilization-blaming
still exercises a powerful Romantic hold, largely over those who are the greatest beneficiaries of the civilizing process itself
Wessley (1990) thesis
the origins of ‘ME’ lie not in 1955 or 1934, but in the last century, and in the condition known as neurasthenia
Features of ME
profound physical and mental fatigue, especially after physical or mental exercise, together with a variety of other symptoms especially neuromuscular, cardiovascular and gastrointestinal
ME
Myalgic encephalomyelitis
Behan & Behan, origins of ME
condition results from a virus, and was first recognized at the Royal Free Hospital in 1955
Ramsay (1986), origins of ME
1934
George Beard
- American neurologist
- published his essay introducing neurasthenia in 1869
- definitive clinical text published 1880
Wessley (1990), five essential themes to Beard’s neurasthenia
- profound fatigability of body and mind were the principal symptoms
- organic disease
- common in educated and professional classes
- resulted largely from environmental factors
- treatment was rest
Wessley (1990) ME similarities to Beard’s neurasthenia
- assumed that ME is an organic disorder of the peripheral or central nervous system. ‘purely organically and virologically based’ (Smith, 1989) (shift from early emph on neurological features to emph on absence of abnormal neurological signs)
- emph on muscle fatigability and mental fatigability
- similar list of over 70 symptoms including alterations in temperature regulation and difficulties in accommodation
- refusal to acknowl existence - Beard’s accusation of docs’ refusal; principal theme of most ME self-help lit = absence of recognition accorded to patients
- disorder of mood / depression
- patients’ mistrust of psychiatrists - belief (also widespread among docs) that psychiatric diagnosis implies denial of reality of distress and illness
- restricted to developed nations
- infectious origin (w neurasthenia, this followed revolution in bacteriology 1870-1900)
- rest vs activity debate
MacDougall (1899) and fatigue
impossibility of measuring objectively a personal experience such as fatigue
Wessley (1990), problem with the nature of fatigue
on one hand, vague sense of being under the weather - reported by most ppl most of the time
Other hand - profound disabling fatigue state
is there clear cut-off between the two extremes?
Using data from
the 1987 US General Social Survey it has been shown (Wesseley & Thomas, 1989):
Some degree of fatigue is found in nearly all the population, but only a very small minority report severe fatigue
The number of fatigue symptoms endorsed is more important than any single item, supporting the concept of fatigue as a dimensional rather than a categorical variable.
Wessley (1990), Reasons for positive social class gradient in neuraesthenia
alleged aetiology
George Savage (1875) - fatigue was commonest in professions requiring an unflagging devotion to work, or a high degree of emotional stress (he listed architects, surveyors, policeman, artists, etc)
Kraepelin (1902), neurasthenia
one of the products of civilisation, confined largely to the professional and clerical callings, and to women of the middle classes
Wessley (1990), med lit became more sympathetic towards neurasthenics for a time
Physicians then (and now) displayed sympathy towards their patients based on their perceptions of whether the illness was acquired through praiseworthy or contemptible means.
Neurasthenia, the disease of overwork, came into the former category
Wessley (1990), neurasthenia’s decline
With the decline in neurasthenia, and its partial replacement by the concept of neurosis, patients were treated less sympathetically by the non-psychiatrist.
By World War I both neurasthenia and hysteria were held in low medical esteem (Stone, 1985), although this was tempered by the fact that neurasthenia was the disease of officers
Perhaps the term neurosis (or any psychiatric label) was interpreted by the unsophisticated doctor as implying that the patient was responsible for their disease, and thus less liable to sympathy
Oppenheim (1908), spread of neurasthenia
great harm resulted from patients meeting in sanatoriums and ‘spreading the mental infection by constant conversation and comparison of their complaints
Wessley (1990), organic vs functional
Ideas concerning organic versus functional lie at the heart of the both neurasthenia and ME. Beard’s neurasthenia began as a physical disease, which may have accounted for its success.
Beard on modernity, 1880
The prime cause of modern nervousness is modern civilisation
- environmental causes: newspapers, steam, science and wireless telegraphy = principal offenders
- pace of modern life
neurasthenia resulted from ‘overload’
Rabinbach (1982), causes of fatigue and exhaustion
less the result of overwork, but more of the work-ethic itself, the drive to succeed.
He shows that fatigue was seen in professions demanding an ‘unflagging devotion to the task or a high degree of emotional pressure
Macintyre (1989), ME
‘disease of the twentieth century’
Steincamp (1989), ME
‘an overload disease unique to this century’
Wessley (1990), origins of neurasthenia/ ME
Obviously some modern causes were unknown to Beard, for example ‘agent orange’ (Hall & MacPhee, 1985) or pesticides (Dawes & Downing, 1989), but the idea of illness created by an external’ toxin’ was entirely familiar.
Even current theories implicating the immune system are consistent with Beard’s views, since the alleged dysfunction is blamed on the excesses of modern living and the ‘deteriorating quality of the world we live in’ (Dawes & Downing, 1989), via notions of overstressing of the immune system
ME blamed on:
- widespread use of antibiotics
- altered environmental factors such as pollution with tobacco, petrol or other allergens making victims more susceptible
- excessive exercise
BMJ editorial 1909, ‘Neurasthenia and Modern Life’
rather than identifying a major health problem, neurasthenia was the problem
‘it is neurasthenia which breeds the almost universal anxiety about health which is one of the signs of the times. This leads to a corresponding prevalence of quackery of every kind’
Wessley (1990), one reason for rapid rise of ME
nature of the principal alleged aetiological agent
Viruses are among the commonest explanations given for nonspecific transient illnesses that abound in the community
The agent is external, and is beyond the subject’s control
no guilt or self-blame
External attributions of illness to entirely organic causes distinguish ME patients from matched psychiatric controls
Wessley (1990), reasons for decline of neurasthenia
- neurasthenia was shifting from being the concern of neurology to psychiatry. This change was of critical importance, since once neurasthenia was viewed as psychiatric, a principal social function was lost.
- increasing sophistication of psychiatric nosology rendered the diagnosis untenable. In the USA Dana (1904) began the protest against the broad definitions and lack of precision
- change in social demography. From disease of upper classes to lower classes. Savill, first to study neurasthenia in a ‘Poor Law Infirmary’, stated that the illness was actually more common in that setting: neurasthenia was now ‘a disease of clerks’
Gosling & Roy, 1986
The neurasthenic model, valuable because it gave credence to non-verifiable symptoms and to emotional distress that was not outright insanity, was dismantled when it proved too large and cumbersome to be subdivided into more specific categories
Farquahar Buzzard (1930), neurasthenia
the label of neurasthenia is often in order to evade a duty - the duty imposed on us to declare a correct diagnosis
Wessley (1990), status of neurasthenia in different nations
England - did not fare well
Clark, Lancet, 1886 - ‘vicious, inaccurate and therapeutically misleading’. It was a ‘an assemblage of incoherent indications of disorder borrowed more or less freely from inchoate forms of insanity, and from almost every disease of the nervous system
Wessley (1990), failures of medical model
neither neurasthenia nor ME fits into a simple medical model
failures of a medical model are not corrected by studies that ascribe psychiatric diagnoses to many (but not all) of patients with ME syndromes
both neurasthenia and ME can only be understood within their social context.
Wessley (1990), what happened between end of neurasthenia and arrival of ME?
Physicians wrote occasional papers on ‘Chronic nervous exhaustion’ (Macy & Allen, 1934) or neurocirculatory asthenia (Wheeler et al. 1950), but more often patients were simply described by their symptoms, such as ‘ exhaustion’ (Dowden & Johnson, 1929), ‘tired, weak and toxic’ (Alvarez, 1935) or simply ‘weak and fatigued’ (Allan, 1944)
Wessley (1990), social processes that govern creation of neurasthenia/ ME
one may argue that they represent culturally sanctioned expressions of distress, in effect culture bound syndromes
difficult to ignore the parallels between attitudes to work and material success between the late Victorian age and now, the periods of neurasthenia and ME, and not to suggest that the intervening years were characterized by different attitudes to both work and the expression of emotional distress
Wessley (1990), stigma
psychiatric illness remains as stigmatizing as ever
dislike and distrust shown by patients and doctors towards psychiatry. This may be direct, but is more often indirect, indicated by the many statements affirming the ‘genuine’ or ‘real’ nature of ME
Olshansky and Ault (1986) fourth stage in epidemiological transition
Based upon the analysis of mortality, life expectancy, and survival data for the United States from the turn of the century to 1980, and projections to the year 2020, the United States appears to have recently entered a fourth stage in the epidemiologic transition - characterized distinctly by rapid mortality declines in advanced ages that are caused by a postponement of the ages at which degenerative diseases tend to kill.
“The Age of Delayed Degenerative Diseases”
This stage will propel life expectancy into and perhaps beyond eight decades
tobacco tokens
govt gave them as economic supplement to old age pensions
nicotine replacement therapy
free to those in
deprived areas as a remedy for inequality.
Berridge (2007), post-war public health + smoking timeline
- 1950s, issue of smoking and lung cancer crystallized
the post‐war change of emphasis from acute infectious to chronic disease and the beginnings of a new lifestyle‐oriented, activist, single-issue, public health - this came to fruition 1970s
- 1980s, passive smoking symbolized the reincorporation of environmentalism within public health
- 1990s, the ‘discovery of addiction’ for
smoking also typified new developments in public health. These entwined prevention with treatment, and gave a greater role for pharmaceutical interventions and for genetics
sigificant change in attitude of govts - took on the role, not without discussion, of
advising on and regulating the individual health behaviour of the electorate.
Berridge (2007), definition of public hlth, adapted from 1988 Acheson Report
the efforts of societies and individuals to prevent
disease, prolong life, and promote health
Berridge (2007), 19th-C public hlth and smoking
Nineteenth‐century public health paid little attention to smoking as a health hazard, and its health dangers were little discussed
Its health benefits were more central and were recognized to include alleviation of stress
the smoker might be weak willed but he was not diseased.
Berridge (2007), dangers of smoking being realised
during the inter‐war years, statisticians like the
American Raymond Pearl, working for the insurance industry, began to
link smoking to reduced life expectancy and to cancer.
In Britain in these interwar years, there was little connection between
formal public health and opposition to smoking
MoHs worked to contain infectious disease
Berridge (2007), lifestyle strand of social medicine/ public hlth
located in the post‐war rise of chronic disease and the rise of risk factor epidemiology
public health focus on these ‘diseases of affluence’ was what lay behind the reorientation of ideology
Smoking and related lifestyle issues brought a new style of health activism into public health. Single‐issue organizations developed science‐based campaigns: the role of the mass media in public health initiatives became central, as a tool to be used, or as a mode to be attacked when used by others
Berridge (2007), new public hlth
1962 report on smoking produced by the Royal College of Physicians was the harbinger of a (16) new
media‐based role for medicine
Science, initially epidemiology, was central to the focus on lifestyle and risk. A population‐level style of argument nevertheless placed its emphasis on modifying the behaviour
of individuals
Health economics, psychology, and the social survey, outgrowths of social medicine, became the standard tools of this new public health.
Berridge (2007), definitive assoc between smoking and lung cancer
Concern was roused by the gradual increase in the incidence of cancer
work carried out in the Statistical Research Unit at the London School of Hygiene and Tropical Medicine (LSHTM) by Professor Bradford Hill and Dr Richard Doll. The results, published in the British Medical Journal (BMJ) in 1950, concluded that there was a ‘real association’ between carcinoma of the lung and smoking and that smoking was a factor, and an important one, in the production of carcinoma of the lung.
Work by Wynder and (25) Graham in the United States, published just before, had come to similar conclusions.
In the UK context, the work of Doll and Hill was the watershed. This was a case control study based on twenty London hospitals.
The Parliamentary Secretary to the MH on 27 June 1957 expressed for the first time unambiguous support for the conclusions reached by Doll and Hill in 1950.
–> MH circular encouraging local authorities to develop health education campaigns on smoking
Berridge (2007), smoking and postwar public hlth
smoking was the exemplar of what came to be the main style of postwar public health. Such a style emphasized the role of individual behaviour, legitimated through population‐based epidemiology, as the dominant focus.
major change away from explanation in terms of social structure, economic inequality, occupation, or environment. Smoking
and lung cancer epitomized this pending change and helped to accelerate it.
The RCP report in 1962 was the catalyst for a new era in which the presentation of science to the public
through the media with the authority of scientists and the medical profession became central.
As consumerist trends in society consolidated, and medicine and public health both sought ‘modernization’, the old tradition of ‘giving the facts’ to citizens was transformed into warnings about health risk.
Berridge (2007), epidemiological shift
Between the 1840s and 1971, three‐quarters of the
improvement in death rates had been due to the decline in infectious
disease, with non-infectious conditions accounting for the remaining quarter. But this pattern changed after the Second World War. The old
‘public health’ diseases like TB or diphtheria were in decline. For TB effective chemotherapy, and mass radiography, virtually eliminated the need for treatment by the mid‐1950s
As the population lived longer, so noninfectious
causes of death such as heart disease, strokes, and cancer grew in importance.
Berridge (2007), what was social medicine?
Concept of social medicine remained vague. Although to Ryle it symbolized the combination of social conscience with clinical
medicine, other leading proponents like Richard Titmuss and J. N. Morris attached importance to the involvement of social science, the use of epidemiology, and the study of health policy.
Berridge (2007) smoking and risk
Legitimizing the smoking and lung cancer link was the first stage in the establishment of society focused on individual health and obsessing over the concept of risk
Environmental concerns were changing to population ones and to the focus on risk.
1960s, research and the social survey began to outline a new view of ‘the public’ and to establish a relationship between medicine and the social sciences
Governments assumed a new duty to advise and warn about health risk, to persuade their citizens rather than to assume that a sense of public duty inherent in the population would lead them to make up their own minds
Berridge (2007), twenty-first c public hlth
the early twenty‐first century was in sharp contrast to the 1950s, with public attention focused on public space rather than(p.281)the private and family realm, the regulation of domestic space and the home being the traditional concern of public health
Public health retained the emphasis on the role of the individual lifestyle, but increasingly this contained a strengthened criminal justice and punitive approach with a particular emphasis on the regulation of public behaviour by young people.
By the end of the century, many of the public health tactics and concepts which were novel and unusual in the 1950s and 1960s were so commonplace as to be unremarkable. People expected doctors to give advice on lifestyle conditions and politicians to give advice on how the population should eat and drink. Government itself had become a public health activist.
The reorientation of epidemiology post‐war to(p.282)concepts of risk in relation to chronic disease were part of everyday currency, although they had been novel and lacking in legitimacy in the 1950s
Weisz (2014), origins of ‘chronic disease’
chronic disease - though a traditional med term - was primarily an American policy construct during the first half of the twentieth century
Weisz (2014), chronic disease pre-20th C
hundreds of books on chronic disease were published in the 18th and 19th centuries suggesting it was far more common than official mortality statistics or historians’ focus on infectious diseases wld suggest
chronic diseases were not a major category for public hlth
William Osler, Principles and Practice of medicine (19th C)
many of those who died of infectious disease already gravely ill
Secondary terminal infections carry off many patients w incurable disease
Weisz (2014), difficulty of knowing prominence of chronic diseases pre-20th C
difficulty of docs getting fams to talk about such matters
implication of hereditary taint or wrongdoing
1905 Massachusetts census
- 12 per 1000 responders had an acute illness
7. 9 per 1000 had a chronic illness
J M Charcot, Lessons on Chronic disease (1868)
most famous 19th-C med work on the subject
Weisz (2014), chronic disease 20th C
term acquired new meaning as one of the most serious problems facing national hlthcare systems
Weisz on Armstrong
Armstrong has assoc the spread of the notion of chronic disease w the rise of a new kind of med - ‘surveillance med’ - replacing the hosp med that predominated for nearly 2 centuries; this regime takes patients out of hosps and focuses on prevention of a growing num of conditions through ever-more pervasive and sophisticated forms of monitoring and screening
however, surveillance and preventive med began w infectious diseases like TB and syphilis
Weisz (2014), rise of chronic disease as category - US
- interwar campaign for physical examinations
- New York City campaign to rationalise hosp and welfare institutions
- National Heath Survey - established in the public consciousness that chronic disease was a major public hlth problem - estimated more than 1/6 American ppl have some chronic disease or impairment
- 1940 American Hospital Association and American Public Welfare Assoc published statement about need to improve institutional care for the chronically ill
- Commission on Chronic Illness 1949-55. final report transformed concern that had achieved significance during the 1930s as part of drive for national hlth insurance into an autonomous issue of substantial import for the hc, public hlth and social services professions
Weisz (2014), reasons for unique US concern w chronic disease at begin of century
- Older population of Britain (few percentage points) - US preoccupation w chronic illness predicated on assumption it affected large nums of young or middle-aged men and women. Cure = national priority. Illnesses of older ppl appeared part of natural order
- US wealthier and not burdened w having to pay for national hlth service/ insurance
Weisz (2014), shift of US ideas on chronic disease to Europe
- 1951, International Congress on Hospitals in Brussels - devoted to chronic and elderly patients
- 1957, European Section of the WHO held symposium in Copenhagen on the Public Hlth Aspects of Chronic Disease
Weisz (2014), chronic disease UK, pre-WW2
- national public system of British Poor Law
- inadequate but divisions in Poor Law Commission 1905
- National insurance. Debate centred around plugging holes in this rather than specific issue of ‘chronic disease’
- statisticians generally skeptical about data showing dramatic rise in mortality from cancers and coronary diseases
- unlike in US context, less reason to mobilise issue of chronic disease to create change bc change already underway
Weisz (2014), chronic disease UK, post-WW2
-series of regional reports based on survey of hosp accommodations carried out during the war by Nuffield Provincial Hosps’ Trust and Min of Hlth, published 1945-6. Gave impression of inadequacy - chronic patients parked in inferior facilities of welfare authorities.
Half all chronic patients in public assistance sector. Understaffed - seen as dumping ground for elderly and chronically ill. Increasing concern w elderly
- 1949, BMA and other agencies reporting that general hosps refusing to admit many older patients
- 1953, Ministry of Hlth, Boucher Comte to examine services to the chronically sick and elderly. 1957 report - hosps generally adequate. need for improved rehab services
-Thomas McKeown - 1960s, had accepted 2 key ideas of US chronic disease movement - developed societies faced new set of illnesses that cld not be dealt w w trad means.
One cld best prevent such diseases by modifying individ behaviours
- 1963 talk at Royal Society of London, Morris (leading social med exponent), referring directly to larger category of chronic disease as scourge of new vulnerable group of middle-aged, emerging since WW1
Morris - ways of healthy living, needed to avoid dangers e.g. air pollution. Also obesity, smoking, stresses.
It was thus poss to think beyond individ diseases to more general category, ‘chronic illness’
By mid-1960s such thought widespread
Weisz (2014), reason for limits to chronic disease model success UK
focus on modification of individual behaviour fit less comfortably into public hlth thinking in Britain than US - in former, longstanding public hlth tradition concerned w hlth inequalities based on social class
Gijswijt-Hofstra (2001), example of key difference between national cultures of neurasthenia
degeneration became inextricably bound up w German and French med discourses on neurasthenia from the 1890s onwards.
British and Dutch med discourses, this seems to have been much less the case
Gijswijt-Hofstra (2001), shifts in neurasthenia concept
somatic to psychic early 20th C
illness of weakness to one of ove-excitement
Gijswijt-Hofstra (2001), neurasthenia and class
Britain - only in wake of WW1 do we hear of shell-shocked soldiers being diagnosed as neurasthenic as means of getting social insurance - may assume that diagnosis of neurasthenia was not as widely extended to the British working-class as was the case in Germany
Porter (2001), nervous disorders prior to neurasthenia
1660s - Thomas Willis - study of nervous system revealed hidden causes of diseases and symptoms
1730s - George Cheyne - 1/3 of all disorders = nervous
Porter (2001), George Cheyne, the English Maladie
fashionable living = deleterious, w its late rising, later nights, artificial lighting and heating, sophisticated cuisines w dishes rich, salted, sauced, pickled, highly-seasoned, and liquors
Porter (2001), entropy theory - borrowing from physics
mid-19th C - second law of thermodynamics posited that the quantum of energy avail in the Universe decreasing
entropy theory incorp into med - Maudsley - energy of the human body = definite and not inexhaustible quantity
Porter (2001), Beard (New York neurologist) and neurasthenia
1st outlined 1869
anxiety, despair, insomnia, fatigue, migraine, palpitations…. etc
disorder of modernity - US nervousness = ‘distinguished malady’, product of US civilisation
insufficient nerve force = explanation for every neurasthenic symptom
Porter (2001), Beard’s ideas cross to Britain
mixed reception
some approved - brought coherence
others less willing to forego old diagnostic categories of spinal irritation of hysteria
Porter (2001), downfall of neurasthenia
when its claimed neurophysiological foundations were not validated - increasingly vulnerable to charge it was merely terminological fig-leaf to cloak ignorance in cases of what was essentially (merely) a psychological condition
Porter (2001), key difference between old conditions of nervousness - the English Malady - and the new American nervousness
English Malady = refinement of the old pathology of luxury
American nervousness = disease of labour
Lutz (2001), peak in num of neurasthenics US
1900-10
Lutz (2001), Beard, by 1881, w publication of American Nervousness
emph moved from physiological to more specifically include cultural factors - steam power, press, telegraph, sciences and mental activity of women
preferred cure = application of electric current to replenish the nerve force
Lutz (2001), Mitchell, Fat and Blood
treatment regimen of diet, rest, massage and electricity
Thompson (2001), shift away from neurasthenia diagnoses
- shift from body to mind - rise of idea of power of mental suggestion
- decline of neurasthenia not as fast as sometimes thought - resistance to rise of psychology
- in exasperation at persistence, one doc in 1930 complained about ‘dumping ground of neurasthenia’. Late as the 1950s GPs still to be found utilising the unreliable and vague diagnosis
- rise of interventionist state, National Insurance Act, rise of panel docs w sense of duty to reduce cost to state. Aftermath of national mobilisation of WW1 - mental hygienists claiming that conditions like neurasthenia were huge financial burden on the nation.
- patients - not declining purely against what patients wanted, as Shorter claims. Some were accepting of psychological over somatic illness definitions - catered better to spirituality through discovery of the whole self. Also, forcing patients to acknowl psychological basis of conditions like neurasthenia cld be attractive and empowering
Aronowitz (1997), first reported ME epidemic
Los Angeles County General Hospital 1934 - outbreak of ‘atypical poliomyelitis’
Aronowitz (1997), aftermath of 1934 outbreak
subset from the LAC outbreak suffered from prolonged and recurrent symptoms e.g. group of nurses
1950s LAC epidemic featured prominently in number of reviews. New syndrome defined - most commonly called benign myalgic encephalitis
Aronowitz (1997), Chronic Fatigue Syndrome
its brief history spans less than a decade
early 1980s - case series describing lingering viral-like illness, manifested as fatigue and other largely subjective symptoms, which appeared to be assoc w serological evd of recurrent or prolonged infection w the Epstein-Barr virus (EBV)
Outbreak at Lake Tahoe
April 1985, conference on chronic Epstein-Barr virus infection
1988, growth in skepticism in med literature. Call to rename, to CFS, as new consensus stressed minimal diagnostic utility of the EBV serological tests
Conference participants proposed ‘Chinese menu’ approach to diagnosis - presence of symptoms meeting two major plus any eight of fourteen minor criteria
series of studies cast doubt on somatic basis of the syndrome.
Few demonstrated high rates of prevalence of psychiatric disease among ppl w CFS
Aronowitz (1997), importance of pathobiological mechanisms in defining and legitimating diseases
CFS gained notice as a new disease only as result of attention given to the apparent correlation between abnormal EBV serologies and a vague viral-like illness
Aronowitz (1997), attitudinal factors influencing rise of ME
docs had only their clinical judgement to distinguish polio from other diseases.
Public hlth officials, believing import of early diagnosis and fearing polio upsurge, launched campaign to raise public awareness about protean nature of the disease and need for early recognition.
Patients thus more prone to detect symptoms and seek med attention
clinicians likely to have lower threshold for suspecting polio
Aronowitz (1997), disease advocacy’s import in devel of ME
fact patients at LAC and Royal Free epidemics were themselves h-c professionals lent weight
Mary Bigler, head of LAC contagion unit, took ill June 1934, and later co-authored one of the epidemiological review of the outbreak
Aronowitz (1997), newspaper reports
probs major influence on lay and med interp of ubiquitous background complaints and self-limited illness as due to polio
Aronowitz (1997), Aronowitz (1997), ecological relationship
ME wld not have captured attention on clinical grounds alone - needed polio as vehicle for recognition
perception of CFS affected by the contemporary AIDS epidemic
Aronowitz (1997), import of economic factors
e.g. early in the Los Angeles epidemic, public hlth authorities used the stark incidence figures to justify increased public hlth spending
Aronowitz (1997), CFS/ ME controversy
diseases caused by virus or hysteria?
both sides of the debate have acted as if the onus of responsibility falls much more severely on the patient whose disease does not have a specific somatic etiology
Tension between critique of med authority and the desire for its acceptance of the patient’s condition as a normal disease
some arguing against the disease see it as potential undermining of med control (much more up to patient to ‘define’ the disease/ how they experience it) and potential source of abuse of the sick role
overall faith of both sides in sci to eventually get things right, and high regard placed on attaining legitimacy of med professsion
Aronowitz (1997), ‘yuppie flu’
journalistic accounts have used terms ‘yuppie flu’ and ‘Hollywood blahs’ for CFS, suggesting it may result from the stress of being an ambitious young professional - e.g. Cleveland Amory
Aronowitz (1997), explaining rise of CFS
convergence of interests - docs, helping them to explain encounters w patients in which disease cld not be diagnosed
-patients - absolution from responsibility, relief from uncertainty, promise of therapy
Yuval Noah Harari, ‘Sapiens’
obesity is the result of our hunter gatherer instinct to gorge on high calorie foods when they’re presented to us
But modern life has made it so readily available the instinct no longer serves the same purpose and now it’s making us really fat
Rippe, Crossley, Ringer (1998), increasing obesity prevalence
Health and Nutrition Examination Survey -
increase of 40% between 1980 and 1990
currently more than 1/3 of the adult US population is obese
described by WHO as ‘escalating epidemic’, ‘one of the greatest public hlth problems of our time’
also epidemic of child obesity - greater than 10% of 4-to-5-yr-old children currently obese
Rippe, Crossley, Ringer (1998), obesity as chronic disease
obesity is a chronic disease that is long-term or lifelong condition for most persons
Rippe, Crossley, Ringer (1998), greater risk of comorbid conditions when obese
e. g.:
- coronary heart disease
-type 2 diabetes
more than 80% of individs w type 2 diabetes are obese
- stroke
- sleep apnea
Rippe, Crossley, Ringer (1998), etiology of obesity
- genetic factors (implausible argument for recent dramatic surge in prevalence)
- lifestyle factors
Surgeon General’s report Physical Activity and Health - only 22% US adults regularly active at the 30 minutes per day lvl - environmental facotrs. Technology decreasing need for physical activity, plentiful and energy-dense food.
US food industry - produces more than 3,700kcal food everyday for every man, woman and child and spends billions advertising - nutrition factors
Rippe, Crossley, Ringer (1998), treatment of obesity
hc community in general and physician community in partic has not been active enough in treatment of obesity as a chronic disease
recent survey - fewer than 40% of the overweight and obese men received counseling concerning the adverse health consequences of their increased weight
most current insurance plans do not reimburse for obesity-related therapies
some stigma on part of physicians - seeing as self-inflicted
importance of variety of therapeutic approaches - nutrition, excecise
chronic disease treatment model shld be used for obesity
Abdel Omran, 1971, epidemiological transition
Three successive ages of mortality.
- Stone age until eighteenth century: pestilence and famine.
- Victorian age: pandemics (receding).
- Twentieth century: degenerative and man-made conditions.
Timmerman (2011), Chronic diseases in the longue duree
‘chronic, incurable illness, leading to slow but apparently inevitable deaths, has a history that long precedes the twentieth century and has been blamed on civilisation by many past commentators’
Timmerman (2011), dropsy
- associated with cold and heavy drinking, caused fluid buildup
- like consumption, diagnosis based on symptom manifestation, causes found in biography/lifestyle
- Richard Bright (1789-1858)’s urine test meant patients could be diagnosed with ‘Bright’s Disease’ with no symptoms
- Triumph for pathological anatomy
Timmerman (2011), New conceptions of epidemiologic transitions in the modern world
J. Michael Gaziano, ‘Fifth Phase of the Epidemiologic Transition: The Age of Obesity and Inactivity
J. Olshansky and A. B. Ault, ‘The Fourth Stage of the Epidemiologic Transition:
The Age of Delayed Degenerative Diseases’
The development of theories of ‘modern’ diseases in the 19th century
A Socio-pathological view?
Porter, R., ‘Diseases of Civilisation’
The manifestations of insanity had traditionally been understood to be either supernatural in origin (visitations of God or the Devil) or essentially organic, provoked by an excess of black bile (melancholy), or yellow bile (choler), or by some brain defect. Now a socio-pathological account achieved popularity. Madness was increasingly seen as in the mind,
a disorder of the imagination or understanding.
It was, in other words, psychological, and the realm of the psyche was viewed as being significantly programmed by the ensemble of linguistic, literary, and intellectual signals in cultural circulation (for example Methodism, Romanticism)
Have infectious diseases been superseded by ‘modern diseases’?
Porter, R., ‘Diseases of Civilisation’
- as the airborne and water-home infections
classically associated with high-density living (typhoid, diphtheria, tuberculosis,
etc.) have been vanquished, new classes of diseases have gained in prominence:
cardiovascular disorders, degenerative conditions of the nervous system, hypertension, diabetes mellitus, cirrhosis of the liver, the cancers, Alzheimer's disease, depression, chronic fatigue syndrome
How well did you k
Porter (1993), a few causes of diseases of modern life?
atmospheric carcinogens, obesity,
cigarette smoking, addictions
Modern medicine as a ‘disease of modern life’ (?!)
Porter, R., ‘Diseases of Civilisation’
Ivan Illich, argues that modem medicine is one
of the prime diseases of civilization, not only spreading iatrogenic disorders,
but orchestrating a disabling ‘expropriation of health’. Illich has commended
the health and disease cultures of simpler times and peoples.
Berridge on chronic diseases in modern Britain
‘The key to the new post-war public health would be a revised epidemiology which dealt with chronic rather than infectious disease’
Berridge on ‘changing patterns of disease’
- The traditional focus on public health had been the outbreak of epidemic…but this pattern of disease and disease-related mortality began to change in the middle of the twentieth century.
- As the population lived longer, so non-infectious causes of death such as heart disease, strokes and cancer grew in importance.
Decline of infectious diseases and its impact on death rates
1840s-1971, 75% of mortality rate reduction due to decline of infectious disease
NEURASTHENIA: Who invented the term ‘neurasthenia’?
- George Beard, Boston Medical and Surgical Journal 1869
- Van Deusen also used the term that year
NEURASTHENIA
Primary source: the fashionability of neurasthenia
French doctor:
‘everything could be explained by neurasthenia: suicide, decadent art, dress and adultery’
NEURASTHENIA
What was neurasthenia?
- ‘a disease of the nervous system…characterised by enfeeblement of the nervous force.’
- ‘nervous exhaustion, characterised by undue fatigue and muscular weakness’
An exceptionally broad church:
1) male hysteria
2) chronic fatigue
3) depression
4) prototype and foundational for other diseases
NEURASTHENIA and modern life
- ‘It was doubted if neurasthenia really was ‘a disease of modern life (Schofield, 1908)
- we had become more tender in our ills - Dubois, 1909
OBESITY
Why does obesity occur in the 21st century?
- we live longer, have less physically stressful occupations, and have easier access to food
- a mental illness on the spectrum with anorexia nervosa
- access to poor food
- addiction
- genetic: an ‘ob-gene’
OBESITY?
Counter argument to premise that obesity is a disease of modern life: the ob-gene
Jeffrey M. Friedman discovered the ob-gene,
Working with a special strain of mice, he set out to identify the hormone that normal animals use to control their appetite - a molecule that was missing in the plump rodents. After eight years he found it
The OB gene encodes leptin, a hormone that inhibits hunger
OBESITY?
Counter argument to premise that obesity is a disease of modern life: anti-medicalisation
‘One social product of the stigmatisation of the obese by the 1960s was the appearance of advocacy groups of overweight individuals who argued not only that their bodily status should not be stigmatised but also that they were happy and proud to be fat.’
NAAFA (1969): to ‘eliminate discrimination based on body size’. Later splintered into offshoot groups
–> obesity ‘a natural state or a disease process’?
OBESITY
Statistics on OBESITY in the uk now
- As of 2013, UK had the highest obesity level in Europe
- 24.5% of uk obesity
- By 2050, could be 50%
SOURCE: NHS Live well
- more commonly lower socioeconomic and socially disadvantaged
groups
OBESITY:
Longue-duree perspective on Obesity:
A. V. Cornaro, Discorsa della vita sobria (1558)
- claims his gluttony ‘kills every year’
- physicians encourage Cornaro to diet
was certainly ill with many of the diseases attributed to obesity in the Galenic tradition: “I had pains in the stomach, frequent pains in the side, symptoms of gout, and, still worse, a low fever that was almost continuous; but I suffered especially from disorder of the stomach, and from an unquenchable thirst.”3 But he also lost his ability to reject temp- tation, having become addicted to eating and drinking.
OBESITY
A history of weight monitoring from the renaissance to BMI
-S. Sanctorius (1561-1636): weigh body to promote losing excess weight
- 19th Century: Adolphe Quelet, ‘l’homme moyen’—average man—by the mean values of
measured variables having a normal distribution! - Keys proposed in this 1972 article that the index
devised by Quetelet, the ratio of weight over height
squared, now be called the ‘body mass index’ (BMI)
Keys (BMI guy)’s attitudes to obesity
Commentary: Origins
and evolution of body mass
index (BMI): continuing saga
Henry Blackburn* and David Jacobs Jr†
He maintained that obesity was ‘ugly but does not itself cause CHD’,12 and was not necessarily dangerous
for mortality risk in the average working man in the
traditional populations we studied in mid century
- Writing around 1949-1950, aware of potential for obesity epidemic in affluent societies
OBESITY
Victorian attitudes to Obese women
In his 1897 book, The Female Offender, author Cesare Lombroso
“This greater weight among prostitutes is confirmed by the notorious fact of the obesity of those who grow old in their vile trade, and who gradually become positive monsters of adipose tissue.”
OBESITY
Victorian psychological attitudes to obesity
“Obesity always carries with it physical and often mental weakness…”
OBESITY
2012 book Alcohol, Tobacco, and Obesity,
“Clearly, although the strength of these three reform movements and the personnel involved differed across issues, temporal periods, and locales, they were part of a larger Protestant-infused ‘clean living’ movement that ascribed moral value to self-restraint and self-regulation, and condemned ‘pathological’ excess.”
Obesity as a disease, or as a contributor to disease?
Obesity as a disease
Roland T Jung
The Diabetic Centre, Nineusells Hospital, Dundee, UK
Obesity is not just a health risk but a disease. Estimates of the genetic
contribution to weight gain in susceptible families range from 25—40%
Obviously there is a major environmental effect but this genetic susceptibility alone removes this condition from a social stigma to the
disease category
Mortality rates affected, link with CHD
Associated with 45 diseases inc. gout, several cancers, heart disease, t2 diabetes
How is obesity a chronic disease?
Rippe, Crossley, Ringer, ‘Obesity as a Chronic Disease’
- Many cannot easily return/shift to a healthy weight
- For many the transition to being obese is very slow, over several years
- Many go through cycles, returning to a healthy weight before relapsing into obesity again
- Most effectively managed not just with intervention but with management: pharmaceutical, surgical, lifestyle changes
Lifestyle vs heredity?
- Probably 30-40% hereditability
- ‘Clearly, genetic shifts represent an implausible argument for the recent dramatic surge in the prevelance of obesity. Lifestyle factors such as overconsumption of energy and decreases in physical activity offer more reasonable explanations.’
- food intake, esp. high fat, does contribute
- plentiful energy-dense food
Obesity: historical development of scientific and cultural ideas.
Author(s) : Bray, G. A.
Obesity as a modern idea?
It is concluded that most of the concepts which are the basis for research in obesity had their origin in the 19th century and often earlier.
Obesity in Ancient History
D. Haslam, The treatment of obesity: Past, present
and future
Obesity has existed ever since civilisation has
been recorded.
- The Venus of Hohle Fels, a crude statuette of a naked obese woman, is estimated
to be 35 000 years old
in 500 bc, the
ancient Indian surgeon Sushruta described
“obesity, voracity, gloss of the body, increased
soporific tendency and inclination for lounging
in bed or on cushion”
Avicenna, the great Persian physician, prescribed
an appetite suppressant for his obese patients
Hippocrates said, “Men who
are constitutionally very fat are more likely to
die quickly than those who are thin.” Galen of
Pergamon, physician to several Roman Emperors,
described the polysarkos phenotype, who “cannot
walk without sweating, cannot reach when sitting
at the table because of the mass of his stomach,
cannot breathe easily, cannot give birth, cannot
clean himself”
Early modern ideas of Obesity as an issue of willpower
Jean Anthelme Brillat-Savarin (1755–1826), The Physiology of Taste or, Meditations on Transcendental Gastronomy (1825)
“(Obesity) is not actually a disease, it is at least a most unpleasant state of ill health, and one into which we almost always fall because of our own fault.”
Railway spine: diseases of modern technology
Caplan, E. ‘Trains, Brains, and Sprains: Railway Spine and the Origins of Psychoneuroses’
- Railway spine: paralysis, headaches, other ailments, following traumatic high-speed rail crash
- First materialistic (spine)
- Psychological (hysteria/neurasthenia)
Erichsen (1866): ‘concussion of the spine’: must be organic disturbance, as ‘couldn’t fathom’ that men could fall victim to hysteria, too.
Jean-Martin Charcot and Herbert Page, insisted that some symptoms could be caused by hysteria (now known as conversion disorder).
Does PTSD have a universal validity?
Bracken, P. J., ‘Post-Modernity and Post-Traumatic Stress Disorder’, Social Science & Medicine 53 (2001), 733-43
assumed to across cultures and time by Diagnosis and Statistics Manual (DSM, US), WHO
Is PTSD a particularly modern, new, disease?
Bracken, P. J., ‘Post-Modernity and Post-Traumatic Stress Disorder’, Social Science & Medicine 53 (2001), 733-43
While historically there is considerable evidence of
physical and psychological reactions to terrifying events
in the medical and non-medical literature, most of these reports point to symptom complexes which are not
co-terminus with the defined symptoms of PTSD
US Civil War: ‘soldiers heart’ (withdrawn)
WW1: ‘shell shock’ (nerve damage, organic)
–> the
symptoms of these military syndromes were simply not
the same as those of PTSD
Testing hypothesis: the
symptom clustering associated with PTSD
existed before psychiatrists recognised it
as a formal disorder.
Jones et al., Flashbacks and post-traumatic stress disorder:
the genesis of a 20th-century diagnosis
- Tested cases of disordered action of the heart/shellshock/psychoneurosis from Boer to Persian Gulf
- Had to accommodate for changing language (eg ‘flashback’ wasn’t a word in WW2, so included ‘visual hallucinations instead)
–>
- Although we did find cases from the First and Second World Wars which would meet today’s criteria for PTSD, their incidence was significantly lower than for the Gulf conflict. Previous historical investigations have relied on single case studies to make the point that PTSD is a timeless disorder. However, such studies
lack a denominator and are instead based on an active search through historical literature for descriptions that resemble modern formulations of PTSD, while presumably
discarding presentations that
appear different.
——> Our
findings imply that the psychopathology of trauma is not static and that culture has an impact on the expression of distressing memories. There is no single way for human beings to respond to the terrifying events of war, and the concept of a ‘universal trauma reaction’ appears flawed. We suggest that PTSD is one more phase in the continually evolving picture of human reaction to adversity (Young, 1995)
Look After Yourself! Campaign, 1975
‘Do you hold your breath when a man looks at you?
‘You’ll be in better shape all round if you lose a few pounds. And you’ll feel better, too.’
Is your body coming between you and the opposite sex?
Early concern for Modern Life
George Cheyne, The English Malady (1733).
Immoderate and luxurious modern lifestyle was bad for health.
Advocate of vegetarianism.
Diseases of Modern Life, B. W. Richardson, 1876
‘Diseases from Worry and Mental Strain…Influence of the Passions…Impurity of Air’
Discusses dangers of smoking for changes to the blood, but denies smoking causes cancer as ‘Cancer was present for ages before tobacco was introduced as a luxury’
Quote from B. W. Richardson that perfectly captures the debate over ‘modern diseases’
Smoking does not cause cancer: ‘Cancer was present for ages before tobacco was introduced as a luxury’
– Disease is not ‘modern’, but new causes are modern: entertains the idea that cancer may ‘excite, locally…the disease cancer?’
Berridge, ‘Introduction’, ‘Marketing Health’
SMOKING: systematic gradualism and coercive permissiveness
Systematic gradualism was a strategy particularly important in the 1950s and 1960s when smoking as an activity was deeply embedded in society, in cultural and social practices
Coercive permissiveness, on the other hand, was the strategy which emerged in the 1960s and 1970s and grew in importance for public health both nationally and internationally as the cultural significance of smoking began to wane. It argued for individual self‐determination—but within a framework of behaviour increasingly defined by the state.
Berridge, ‘Introduction’, ‘Marketing Health’
SMOKING: Increased opposition and the situation in Britain?
The main period of concern came in the early 1900s when a number of anti‐smoking organizations were founded to oppose smoking in children.
British Lads Anti‐Smoking Union
Work linking Smoking to Cancer in US/Germany
BUT
In Britain in these interwar years, there was little connection between formal public health and opposition to smoking…MoHs worked to contain infectious disease, ….Changing individual habits like smoking were not part of this mindset at all.
Later banned advertising on TV in 1965
Public smoking ban in 2005
Diseases of modern life: Killer Chairs?
This grim conclusion may surprise you, but 18 studies reported during the past 16 years, covering 800,000 people overall, back it up. In 2010, for example, the journal Circulation published an investigation following 8,800 adults for seven years. Those who sat for more than four hours a day while watching television had a 46 percent increase in deaths from any cause when compared with people who sat in front of the tube for less than two hours.
https://www.scientificamerican.com/article/killer-chairs-how-desk-jobs-ruin-your-health/
Berridge, ‘Introduction’, ‘Marketing Health’
SMOKING: not perceived as a disease?
Smoking, it argued, was not a ‘disease’ in the way cancer, or indeed infectious disease was. It might lead to disease, but not for many years. The notion of long‐term ‘risk’, as we have seen, was not yet central to public health in the 1950s.
David Haslam, Naveed Sattar, Mike Lean (2006), Obesity - time to wake up.
Obesity as epidemic
The obesity epidemic in the United Kingdom is out of control,
and none of the measures being undertaken show signs of
halting the problem, let alone reversing the trend. The United
States is about 10 years ahead in terms of its obesity problem,
and it has an epidemic of type 2 diabetes with obesity levels that
are rocketing. Obesity is a global problem—levels are rising all
over the world
David Haslam, Naveed Sattar, Mike Lean (2006), obesity and genetics
global problem—levels are rising allvover the world. Moreover, certain ethnic groups seem to be more sensitive than others to the adverse metabolic effects of obesity. For example, high levels of diabetes and related diseases are found in South Asian and Arab populations
David Haslam, Naveed Sattar, Mike Lean (2006), obesity’s cost in UK
Every year obesity costs the UK economy £3.5bn (€5.1bn, $6.4bn), and results in 30 000 deaths;18 million days of work taken off for sickness each year
Strategies for primary care that encourage primary prevention of chronic disease, including obesity management, would achieve considerable financial rewards
David Haslam, Naveed Sattar, Mike Lean (2006), obesity’s link to chronic diseases - in history
More than 250 years ago, Giovanni Battista Morgagni
used surgical dissection to show visceral fat. He linked its presence to hypertension, hyperuricaemia, and atherosclerosis
NAAFA
the National Association to Advance Fat Acceptance (est 1969)
