Evolving Concepts of Health and Sickness

To return to the nineteenth-century squabble over disease causation, in view of the ineffectiveness of physicians' efforts to control epidemics, their self-confidence appears paradoxical. Considering the provisional, incomplete nature of their etiological knowledge at the time, how do we account for the dogmatism of champions of the two opposing theories, particularly the supporters of the miasmatic hypothesis, which we now recognize as dangerously inadequate in explaining the transmission of plague and cholera?

In the case of Great Britain, the obvious success of sanitary reform in reducing the incidence of waterborne diseases circumstantially seemed to vindicate the validity of the miasmatic theory. Although policy planners ignored John Snow's evidence incriminating water as the medium for disease transmission, by creating sewage systems to dispose of the human waste they believed the cause, they fortuitously protected the water supply and applied the proper remedy, if for the wrong reason. In addition, Great Britain's preeminent place in world affairs cannot be ignored as an important factor contributing to the medical profession's self-confidence. Physicians from British India especially, unaccustomed to having their opinions challenged, could see in Egypt all the features that guided their policies in South

Asia, and they believed they had the answers to what appeared to be analogous social and medical problems.^[17]

Clot is an interesting example of the continental physicians committed to variations of the miasmatic, anticontagionist hypothesis. To his advocacy of "indigenous" institutions, Egypt owes its School of Medicine, the School of Hakimas, the promotion of universal smallpox immunization by village barbers, and the extension of Egyptian physicians into provincial health centers after demobilization of the military medical corps. The initial institutionalization and nationalization of Western medicine in Egypt is largely due to Clot's drive and organizing genius. But on the subject of disease transmission, he was dogmatic. In rebutting arguments for the contagiousness of plague, he loses sympathy when he asserts that by 1840 all enlightened men, "except Italians and Spaniards," had abandoned the idea of contagion for scrofula, scabies, leprosy, ophthalmia, phthisis, dysentery, typhus, yellow fever, and cholera as well as plague. He shudders at the "ridiculous and barbarous custom" of Romans who segregated pulmonary consumption patients from other patients in their hospitals.^[18]

It was the cogency of the Morgagni paradigm that confirmed Clot's frequent diagnoses of "gastroenteritis" by revealing enteric lesions in corpses and strengthened his conviction, enhanced his self-confidence, and led him to doctrinaire attacks on his opponents. By the end of the century, the Morgagni paradigm had vindicated Clot's Italian and Spanish contagionist adversaries by identifying specific microorganisms as the pathogenic agents for the diseases over which they had quarreled. Although both sides believed they were dealing with definitive scientific truths, both theories were only limited, partial, and approximate descriptions of reality.

Concepts of the diesase process have evolved during the intervening century, and proposals for a new paradigm for medicine have appeared in recent decades.^[19] The pathology- or disease-focused concept of sickness sharpened to the principle of etiological specificity, which was vindicated by the bacteriological discoveries of the late nineteenth and early twentieth centuries, provided the perfect key concept for understanding infectious diseases and opened the way for rational therapeutics. The clinical system worked, and by focusing on pathology as the core discipline in hospital training, it established accuracy in diagnosis as the medical practitioner's major aim

and primary skill. The emergence of bacteriology next became the vehicle that first introduced the ideology of science into medicine, and paradoxically it led physicians away from the bedside to the laboratory.

More important for agrarian societies like Egypt, the ideology of science appears to have reinforced the idea that authentic medicine is curative medicine, a more serious pursuit than preventive or environmental control measures. No doubt Egyptian medical students and practitioners who are reluctant to practice in the countryside are influenced by the lack of social amenities, poor accommodations and facilities, inadequate supplies and assistance, and perhaps daunting social problems. But some of their dissatisfaction with rural practice may be attributed to training that encourages self-definition as scientists in the forefront of the latest discoveries. Confronting infectious diseases, the scientist-physician is concerned about the availability of broad-spectrum antibiotics; mounting a campaign of pest control or a program of hygiene education for villagers would be outside his area of responsibility.

The nineteenth-century divorce of the practice of medicine and community or public health concerns may be the most unfortunate aspect of the Western system transferred to the non-Western world. And Western leaders in medical science continue to insist, as one member of the elite of academic medicine declared, that "when the emphasis is shifted from sick individual human beings to people in the aggregate, clinical medicine becomes esoteric medicine, biochemistry and physiology become irrelevant, and the appropriate disciplines are more in the nature of economics and sociology."^[20] As long as the West upholds urban hospital-based curative medicine for the individual as the ideal for "health care," the lives of rural Egyptians and many others may continue at risk.