Key Transformations in the Cultural Evolution of Sickness and Healing

Family-level Societies

Disease and injury could in some ways be said to happen to the group and, correspondingly, to constitute its concern: The well-being of all is at stake, and the course of sickness (particularly a serious one) has group implications. One observes the bare essentials of what natural selection has furnished man in the way of showing and coping with disease and injury and, correspondingly, the culturally least elaborated institution of medicine. These societies mark the takeoff for the social evolution of medicine.

Medical memes stipulate that the self, ancestors, other supernatural agents, and malevolent actions of person from outside groups are held responsible for sickness. The self is punished because of acts of transgression, although he or she may serve as the mere substitute for punishment of others in the group. Explanations of cause and of manifestations (i.e., ethnopathologies) show little elaboration, and medicines and procedures that persons can draw on are likewise little elaborated. No special healers or shamans are found; among the !Kung Bushmen, all adult males appear to function as shamans. A global, group-felt sense of powerlessness, helplessness, despair, and victimization usually accompanies illnesses that are serious and that persist. The manifestations of sickness have little diagnostic value and are handled holistically, all together signaling a state of undesirable morbidity needing healing. No differential value or meaning is accorded specific sickness manifestations. The family and the group as a whole constitute the healing party, and efforts on its part (usually acting in concert) are held to possibly modify the course of sickness with supernatural help. A great deal of resignation exists in the event of sickness, and the expressed well-being and actions/behaviors of the sick person determine the amount of activity or passivity that is sanctioned during sickness. The sick person, in other words, usually in a way that is acquiesced to by the family and group (given the group's highly integrated character), determines wellness and the end point of occupancy of the "sick role."

Village-level Societies

The demography and political economy condition a culture that makes possible a more elaborated, cumulative pool of medical memes; and because of rudimentary social divisions in the population, they stipulate that persons of greater knowledge and power can influence diagnosis and the course of sickness and healing. Medical memes thus allow that sickness and healing are affected by village happenings. As a consequence of intragroup social conflicts

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and rivalries, comembers with whom there is friction become responsible agents of sickness in addition to the other causes found in family-level societies. Medical memes that invoke malevolent actions from neighbors, witchcraft and sorcery from within the group, become possible and persist as possibilities in groups that are more complex. The more differentiated character of these groups also means that the family, and less so the group as a whole, is experienced as the existential target of the malevolent victimization and despair that is experienced during (serious, protracted) episodes of sickness. Likewise, the family, nuclear or extended, plays a more exclusive role in beginning treatment and seeking consultation and help for further healing. Sickness retains its holistic character as in the previous social type, and specific manifestations are not accorded special diagnostic value or social value/disvalue. The sick person, his or her family, and protoshamans constitute the healing party. It is significant that the cumulation of information found in these groups contains more medical memes involving procedures, medicines, and mechanisms of how enemies and competitors can cause sickness and influence healing (what can be thought of as slightly more elaborated ethnopathologies). This means that the individual and his family can begin to use the status of these relationships to influence course by calibrating when and how sickness episodes terminate. In short, exploitation of the sick role is made possible by these types of medical memes that are themselves the outcome of developments outside the institution of medicine. It is also significant that political economic differentiation makes possible the creation of a role of healer since this lays the foundation for the special social and psychotherapeutic influence that specific and charismatic persons who occupy this role can have in the course of sickness and healing. The obligation to reciprocate or remunerate an individual outside the family, and sometimes outside the group itself, is, of course, also conditioned by this new political economy of medicine.

Chiefdoms, Prestates, and States

The distinctive sociological changes noted in village-level societies are accentuated. Medical memes stipulate specialists in the affairs of medicine, meaning that the availability of diversified audiences complexifies both sickness and healing. They also stipulate the need for remuneration of "service" personnel. While these types of medical memes are far more visible and influential in more evolved social types, they make their appearance here. Medical memes are more numerous and specialized with respect to what sickness portends and means and how it can unfold. They allow for different individuals and social circumstances to figure in the equations of sickness and healing as causes, as existential targets, and as individuals to be placated, reprimanded, or ingratiated through more or less scripted rules. Here, memes from other institutions enter into association with strictly medical memes.

In essence, families, clans, and lineages become the responsible agents in the playing out of sickness and healing and the existential import of medical memes encompass these units as well. Medical memes pertaining to the cause of sickness and the efficacy of healing become more differentiated and complex and begin to incorporate distinctive manifestations of disease and injury. While sickness still retains its integrated character with all types of manifestations accorded equal validity, some of these begin to play a more influential role in the ethnopathology, diagnosis, and nomenclature of sickness and the structuration of healing. Although sickness retains its grave, despairing existential import, the greater articulation and systematization of spheres of spirituality and religion with emerging possibilities for perpetuity or rebirth that are found in these societies provide some relief for the existential burdens of sickness. The commitment (or lack thereof) of the family on behalf of the sick person, the influence of specialist healers, and the participation of comembers conceived as causally implicated in sickness all become elements in the working out of curing rituals, allowing sick persons and their families to construct socially rich scenarios of sickness and healing. All of this creates more opportunities for medical memes that allow and facilitate exploitation of the sick role in terms of group interpersonal relationships, the process problematizing the course of sickness, and the perceived and imagined effects of healing.

Empires and Civilizations

It becomes more difficult to speak of a single approach to medicine in these types of societies because of social complexity and differentiation. A large number and rich variety of medical memes are made available to individuals through the literate tradition. While wealthier and politically powerful groups may constitute the principal holders of them, these items of information are widely disseminated in the population and internalized and come to influence how sickness and healing are played out.

Medical memes continue to elaborate religious, especially eschatological tenets, and conflicts with and actions by others as causing sickness and influencing healing. However, the morality, routines, and habits of individuals themselves become important, with these factors contextualized in terms of comprehensive theoretical explanations that prominently incorporate body parts, mechanisms, and functions. Correspondingly, while sickness can continue to be construed as existentially burdening and harming to the family and the immediate group and to reflect malevolence on the part of neighbors and outsiders competing with and jealous of these units, the ill individual comes more to be defined as especially targeted and to embody the existential burden of sickness. Moreover, because of his or her more strategic role, the individual is more influential in manipulating the condition of sickness for his or her own "secondary" needs. The specific manifestations of sickness and injury acquire

a more concrete role in the definition and diagnosis of sickness and in the selection and evaluation of healing. Symptoms of mental illness, particularly those reflecting insanity and madness, tend to be highly discrediting in these types of societies (e.g., India, China, medieval Europe, and early modern Europe). Although sicknesses are explained in a comprehensive psychosomatic/somatopsychic frame of reference, medical memes that stipulate a specifically somatic language of suffering and distress become overvalued as markers of sickness because of the influential role of interpersonal conflicts in causation of sickness generally and because of the more visible and compelling stigma of mental illness that characterizes the large urban centers of empires and civilizations. Healing parties are centered more on the sick person, family members, and healers, with group and clan members less important. All of the latter persons are held to influence the course of sickness. However, the fact that in these types of societies sickness becomes more common, persistent, naturalistically construed, and hence secularized as well as the object of competing commercial interests, the individual who is sick, in his or her more strategic position, comes to play a central role in manipulating and orchestrating its course.

Modern European Societies

The way sickness and healing are structured in these societies is strongly determined by factors external to the medical institution per se. Medical memes stipulate biological reductionism, and the power of biomedicine to explain and control disease induces profound optimism regarding the control of sickness and healing. Medical memes create sickness and healing as objective, mechanical, and technical enterprises focused on the body machinery, with healing aimed at its repair, all of this structured in terms of a fee-for-service framework.

Medical memes stipulate that impersonal agents that disturb bodily mechanisms and processes bear the responsibility for sickness, with causes reduced to disorders of the physical apparatus. Sickness is, correspondingly, devoid of spiritual overtones, constituting a physiologically determined dilemma for the individual to work out with support from the family. Indeed, whereas in previous social types medical memes stipulated that the burdens of sick persons and their families were the "objects" or "functions" of healing, the new ones point to the disease entity invading and inhabiting the individual. The memes elaborate that bodily manifestations of sickness are crucial determinants of diagnosis and treatment and that somatized problems that conform to standard biomedical pictures of disease and injury are the valid idiom of medicine. This means that psychological, emotional problems are discredited as unauthentic and "psychiatric." Indeed, the meaning of psychiatry becomes a meme that plays a dominating role in managing mental illness and embraces coping difficulties and problems of living. An expansion of the kinds of problems addressed by medical memes is noted: A medicalization of deviance is a result, a

development that complements the enormous power and prestige of the medical profession in the society at large to define sickness. Yet more and more, medical memes stipulate a relatively impersonal healing party with a single type of "doctor-patient" relationship as the standard. Usually under the control of specialists, the hospital becomes the identified physical setting for the conduct of healing. The physician becomes empowered as the arbiter of sickness, validating its duration and authenticating the sick role, with sanctions being brought to bear on persons who do not conform to the standard profiles of disease or respond to accepted remedies.

Postmodern European Societies

The impact of memes from other, nonmedical institutions continues to be strongly felt in sickness and healing. More specifically, the sociologic and political economic developments described for modern European societies persist and deepen. Medical memes stipulate that how physicians, the state, and third-party payers model disease and injury constitute authentic protocols of sickness and injury. The communications industries expand and exert a powerful role in spreading the influence of memes pertaining to biomedicine as the standards of sickness and healing. However, the limits of the power of biomedicine to heal and control disease and its effects become integral to what meaning is accorded to medical memes. These recognize the fallibility of physicians, the need to contain medical costs, bioethical dilemmas, and the need for cost-effective arrangements for "managing" sickness and healing, arrangements that threaten to undermine the heretofore special features of the doctor-patient relationship.

The effects of these developments on the properties of sickness and healing can easily be surmised. Since mechanical failures of the body due to degenerative diseases constitute major underlying causes of disease, medical memes stipulate that the individual's habits and behaviors play a dominating role in the cause of sickness. Hence these memes "blame" individuals for sickness and hold them responsible for genuine efforts to pursue preventive, curative, and rehabilitative services that are legally approved. Medical memes stipulate that healing parties are constituted by teams of different specialists and general physicians, with patients consumers of their services. Disease is stripped of larger existential overtones, reduced to mechanical failures of the body. Memes instruct individuals how to monitor their bodies for clues to the diagnosis and treatment of disease as biomedical knowledge becomes standardized, widely disseminated, and almost public. The state, through the medical policing efforts of physicians, sets the criteria for what come to be viewed as the authentic states of sickness and entitlements to treatment (a consequence of biological reductionism and reliance on its technology). The result is that the state, which literally sponsors and supports much of biomedical education

and research, becomes an influential agent in monitoring the course of sickness and the effects of healing in the population. The capacity for individuals to manipulate their role of sickness is further undermined by physicians as agents of third parties who come to exert increasing control of the medical marketplace. Associated with this, one finds dissatisfaction with physicians, with "establishment" medicine, with the escalating costs of a more routinized and procedural approach to healing, and with the tentacles of medical insurance companies. An outcome of this is increasing interest in holistic medical traditions and the growth of health-promoting and life extension industries that compete with orthodox biomedicine.