Characteristics Associated with the Sick Role

It has been pointed out that in chiefdoms, prestates, and states sickness and healing are rendered more abstract medical and sociological objects of the society. They come to acquire fairly standardized and conventionalized social meanings and to play equally important symbolic roles. This is a natural function of the size and complexity of the society. However, a measure of standardization of sickness and healing is complemented and facilitated by the fact that, compared to less evolved societies, in these one observes a general abatement in the onerous, harsh, and demanding conditions of life. This has the effect of removing some of the crisis, life/death, and menacing implications of sickness and healing. Social differentiation and the availability of kin and lineage group mates who can help and offer support render sickness and healing less of an immediate threat to subsistence in many groups of people in these societies. A consequence of all of this is that a scenario of sickness and healing is less prominently shrouded with an ethos of urgency, circumscription, and overt danger.

Provided one keeps in mind that cultural and social circumstances still frame the medical in moral/spiritual as well as secular/empirical terms, that is, in an

idiom very different from that of modern societies, one can rely on what was in an earlier chapter referred to as the "sick role" as a useful concept with which to analyze medical happenings in chiefdom, prestate, and state societies (Parsons 1975). Indeed, it can be said that the sick role becomes more visible and easily manipulated socially. There are several reasons why this is the case. First, the systematization of medical knowledge means that medical vocabularies and sickness and disease* types become objects of common knowledge. Second, the pictures and trajectories of sickness become more clearly profiled given that sicknesses are more common and many of them are chronic and less than lethal or even of serious proportions. Third, given the larger size, greater social divisions, and greater opportunities for social pursuits, individuals interact more and more with frank strangers or true strangers. All of this means that since economic, interpersonal, and psychosocial conflicts are more prevalent in these types of societies, sicknesses will come to be expressed in a more elaborated and social idiom of distress. The result of these and related factors is that the social causes and consequences of sickness become more evident, defining elements that can enter into the causation and/or computation of the "secondary gain" of sickness. Vulnerability to others of the behavioral environment becomes more heightened and, also, the motivation to be sick becomes a more easily visualized, sought after, and realized goal. This expanded ecology and social economy of sickness, illness, and disease* promotes coping by accentuating the need for healing. Thus what many may term (loosely) the social functions of sickness become more prominent and elaborated and this can lead to an enhancement of the appeal of sickness.

These factors relate to what one might conceptualize as the push toward sickness and the adoption of the sick role. At the same time, one must keep in mind that the "social pull" generated by practitioners and the psychological favors they can bestow begins to exert influence on the generation of sickness (see earlier discussion on specialist healers). What are often termed (sometimes too loosely) problems of somatization or "psychosomatic" and "sociosomatic" sicknesses, some associated with more or less consciously perceived political economic hardships, if not frank malingering, become potentially important factors in the social economy of medicine largely because of the independent influences exerted by sociological factors. All of the above addresses the person's conscious intentions and motives and the potential charisma of healers.

The preceding point can be stated differently: the social rationale of sickness is more defined and its rewards increased. The psychosocial needs and conflicts of persons become more important influences in the occupancy of the elaborated role of sickness. In addition, and perhaps inseparably related to this process, "unconscious" factors begin to play a more important role in the social economy of medicine. In other words, because conditions of sickness become prominent symbolic objects in the social and political arena of a community,

they function psychologically so as to facilitate the shaping of physical and psychological stress toward the unconscious production of sickness and eventually disease*.

All of the preceding means that the social ecology of these types of societies create different inputs for the way the SH adaptation comes to be constructed in sickness and healing. As an example, whereas death and termination were entailed by sickness and healing scenarios and a short-term crisis ethos colored medical exegeses, all of these features of the way the SH adaptation evolved during Pleistocene conditions (see earlier chapter), now under very different social and cultural conditions death and termination begin to recede in salience and dominance. Individuals, be they sick or drawn to heal others, begin to be provided with an altogether different calculus or set of rules in terms of which sickness and healing can be configured and played out. One can say that the meanings, rationales, and functions of medicine all begin to change as (what I have termed) a sociological emphasis with amplification and complexification of the sick role begins to operate in the society.

In summary, social conflicts, rivalries, and jealousies are very prominent features in societies at this level of differentiation. States of physical vulnerability are enhanced, as is also the opportunity of contracting infection. Individuals can be said to live in a more precarious, compromised state of physical and psychological health. The psychological and physical stress that is a product of these sociological, cultural, and ecological conditions can be held to predispose toward, if not promote, the outbreak of disease. Moreover, the preceding mix of factors also facilitates the construction of conscious and unconscious motives for sickness and healing since this promises attention to and the possible resolution of social and psychological strains through the intervention of charismatic healers.