Person:

Rosenberg, Charles

Epidemics of infectious disease have always played a role in American history, and such epidemics are sited in time and place and configured in terms of ecology and demography, available medical knowledge, and cultural values and collective experience. The mix of these variables has changed dramatically since the theocratic world of 17th‐century New England, but the relevance of each remains. Avian influenza already exists virtually in Western society in terms of planning, global networks, laboratory research, social expectations, media representations, and a specific shared history based on the memory of the 1918 influenza pandemic.

Erwin H. Ackerknecht was an influential member of that small group of largely émigré historians of medicine who professionalized their field in the United States. Ackerknecht was influenced by both contemporary social science and an implicitly political vision of social medicine. It was a vision reinforced by his work in social anthropology in Paris in the 1930s, and it is a tradition that has its own intellectual pedigree, one that can be traced back to the era of Rudolf Virchow. It was no accident that Ackerknecht wrote on the social and ecological dimensions of disease, and that he was a vigorous advocate of a powerfully felt but, in retrospect, inconsistent relativism. His emphases on everyday medical practice and on siting ideas in their social and institutional context seem prescient, a forerunner of contemporary trends in social and cultural history.

Since the 19th century, we have come to think of disease in terms of specific entities—entities defined and legitimated in terms of characteristic somatic mechanisms. Since the last third of that century, we have expanded would-be disease categories to include an ever-broader variety of emotional pain, idiosyncrasy, and culturally unsettling behaviors. Psychiatry has been the residuary legatee of these developments, developments that have always been contested at the ever-shifting boundary between disease and deviance, feeling and symptom, the random and the determined, the stigmatized and the value-free. Even in our era of reductionist hopes, psychopharmaceutical practice, and corporate strategies, the legitimacy of many putative disease categories will remain contested. The use of the specific disease entity model will always be a reductionist means to achieve necessarily holistic ends, both in terms of cultural norms and the needs of suffering individuals. Bureaucratic rigidities and stakeholder conflicts structure and intensify such boundary conflicts, as do the interests and activism of an interested lay public.

This essay outlines a contextual approach to disease (and thus medicine) in society. The work of Owsei Temkin is retrospectively evaluated and shown to rest on an assumed (if often implicit) contextualism. The key components of historical contextualism are then articulated, including the historicity of disease, the reification of specific disease categories in terms of language and social practice, and finally, in contemporary society, the value placed on diagnosis, the bureaucratization of disease, and a logically consistent focus on boundary management and boundary disputes. It is a contextualism that demands a role for the biological as well as the cultural, for practice as well as pathological theory.