Preface

This book constitutes an attempt to provide a theoretical introduction to the comparative study of medicine as a social institution. I draw on work from many disciplines, including cultural and physical anthropology, sociology, social history of medicine, medical geography, economics, paleoanthropology, paleopathology, archaeology, historical epidemiology, and human evolutionary biology. I cover biological aspects of disease prevalence, characteristics of medical practice, lay and folk as well as practitioner orientations to illness, and the general cultural meanings of medicine in various types of societies.

A fundamental motivation behind the book is that there exists a need to conceptualize medicine in a theoretically integrated way. I am seeking the connections among the biological facts of disease and injury, the social and cultural facts of their expression in behavior that is meaningful, the social responses of healing, and the relationship of all this to characteristics of the society considered as a social structure. Furthermore, I seek a synthesis through an evolutionary formulation of medicine. Such a synthesis will provide unity and balance to the study of medicine, now split along the lines of different academic disciplines and traditions.

I attempt to accomplish this admittedly daunting task by conceptualizing the essence of medicine as centered on sickness and healing. And these basic concepts are handled in biological, social, and cultural terms. My goal is to view sickness and healing from an evolutionary frame of reference. I conceptualize sickness (the behavioral expressions of disease and injury) and healing (the culturally meaningful social responses aimed at undoing or preventing the effects of disease and injury) from the standpoint of biological/genetic and social/cultural evolution.

This evolutionary view of sickness and healing is what maintains the unity of my approach. In my formulation they constitute linked facets of a unique human adaptation developed during the biological evolution of the hominid line and expressed culturally in relation to the changing historical contingencies of social organization and complexity. Sickness and healing are ordinarily conceptualized as different phenomena that are linked, to be sure, in the event of medical care. However, I handle them as "two sides of the same coin." The dynamism of each enters into that of the other; they are constructed out of the same material; they are reciprocal; and they both originate in the same way. They are seen in relation to social and cultural evolution and are analyzed as expressions of an underlying biological adaptation unique to Homo sapiens . This "natural" integration of sickness and healing, natural because they were both sculpted together during evolution, provides a new vantage point from which to examine the institution of medicine.

In chapter 1, I describe some of the problems of studying medicine from a theoretical standpoint, review earlier efforts to conceptualize medicine in biological and cultural terms, including evolution, and set boundaries on what is to follow. In chapter 2, I discuss material related to the origins of sickness and healing during biological evolution. The idea that at the root of medicine one finds a complex but integrated adaptation for both sickness and healing is introduced and discussed using material from evolutionary psychology. The problems inherent in examining sickness and healing in an integrated way and as grounded in evolution are reviewed. In the next two chapters, I go on to review characteristics of sickness and healing during what I term the early and later stages of social evolution, beginning with early, village-level societies, proceeding through prestates, states, and civilizations, and finally including the modern European and postmodern eras. This material, which includes reviews of social organization of the societies, epidemiological and ecological factors, and aspects of sickness and healing in each of the selected social types, is discussed in chapters 3 and 4. Individuals living in family-level societies during the line of evolution to Homo sapiens are judged to have evolved a distinctive framework for medicine. This framework, consisting of orientations and behaviors related to sickness and healing, is judged to have been transformed as societies evolved and became more complex. The two chapters offer a summary account of how sickness and healing have been configured and played out in different types of societies. Some of these ideas on the evolution of sickness and healing are elaborated by discussing the role that active substances and drugs might have played in different historical periods (chapter 5). A more indepth account of sickness and healing in different types of societies is illustrated by giving attention to somatopsychic disturbances (chapter 6). These are important medical disorders in biomedicine today, and there are good reasons for believing not only that they are universal but also that they constitute a good barometer with which to record the interplay of culture, society, and bi-

ology. This line of analysis is pursued in chapter 6. In chapter 7 I introduce the concept of a "medical meme" to refer to the basic unit of information pertaining to how sickness and healing are configured and played out. This concept serves as a bridge for linking the biological and cultural evolution of medicine and is used here and in later chapters as a way of giving substance and focus to the evolution of medicine. In this chapter I also consolidate earlier descriptive material by summarizing general parameters pertaining to sickness and healing in each of the different types of societies analyzed earlier. In chapter 8 concepts and principles are further elaborated in my attempt to conceptualize sickness and healing as well as the institution of medicine in an evolutionary frame of reference. The inner workings of the adaptation at the base of medicine are analyzed more fully. In particular, the role of medical genes in producing the machinery of the adaptation for medicine is discussed together with the relationship they are thought to have to medical memes, which produce the expressive, meaning-centered aspects of the adaptation. In addition, what I regard as the ontogeny of this adaptation is reviewed together with its implications. The adaptation is judged as providing the conditions that together with social environmental inputs pertaining to experiences with disease and injury during critical periods of development lead to the unfolding of sickness and healing orientations and behaviors. Finally, the tie between the material of the adaptation and the material that sociologists and economists have in mind when they discuss institutions and their social evolution is reviewed. All of this provides a way of integrating the study of the biological and cultural evolution of medicine. In chapter 9 I step back and examine aspects of the evolution of medicine from a broader point of view. I present a diagram for illustrating the various types of phenomena implicated in this evolution. The institution of medicine is conceptualized as incorporating differing materials and systems, beginning with genes and ending with social organizations, corporations, and material products. The institution of medicine is connected to other institutional sectors of any society, and these are included in a macrosociological schema of society. The changes in the differing components of medicine and in the society during evolution are summarized. In chapter 10 I discuss some of the implications of studying medicine from an evolutionary standpoint, giving attention to topics in social medicine, clinical medicine, and social theory. In chapter 11 I review my thinking and discuss ways in which an evolutionary perspective on medicine can be used to examine contemporary problems in biomedical practice. In the appendix I summarize my argument by providing an outline of the concepts and a description of the characteristics of the stages of the evolution of medicine.

A general view of my intellectual orientation is appropriate here. A common interpretation of evolution is betterment and progress. it is important to emphasize that with respect to medicine this interpretation is not promulgated in this book.

There unquestionably have resulted enormous gains in the treatment of many types of disease during the rise and development of biomedicine. And prior to this, one could reasonably claim that practitioners of many of the ancient "great traditions" of medicine, such as those of China, India, and the ancient Mediterranean societies, produced more enlightened, successful understandings of sickness and healing compared to other, smaller and less evolved traditions. Even the latter approaches cannot be said to be without their benefits as research studies centered on the value of native healing rituals and local, indigenous medicinal preparations continue to elucidate.

In conflict with a view of the unquestioned beneficial effects of social evolution on health and medicine is the body of work of physical anthropologists on the comparative nutrition and health of prehistoric and early historic populations. This line of investigation tends to support the relatively high nutritional status and physical health of foragers and hunter-gatherers. Moreover, and although this is contested, the consensus of opinion seems to point to possible relative declines in nutrition and health of populations in association with the major social and economic revolutions involving subsistence patterns and population density and size. Based on this line of thinking, then, it would be difficult to conclude that growth and "evolution" of a society's medical tradition and approach to disease, which one can equate roughly with the major social and economic revolutions of human groups across history and prehistory, always resulted in improvement or progress.

It needs to be emphasized, then, that the "success" of a tradition of medicine is difficult to establish and is much contested. Many of the gains in morbidity and mortality associated with the modern era, as an example, have been explained as resulting from improvements in sanitation, hygiene, and diet rather than from medical practice per se. And from a theoretical standpoint, an argument can be made to the effect that the value of a tradition of medical care should be measured in terms, not exclusively of epidemiological indices per se, but of those pertaining to how sickness problems as identified by that tradition are handled. With respect to the latter point, several factors linked to sickness and healing, not just success in eliminating or controlling the underlying disease or injury, should be taken into account, for example, success in relieving pain and suffering, success in facilitating the social losses occasioned by disease and injury, success in promoting sociopsychologic reconditioning, and success in providing for comfortable ways of dying in the event that healing is unsuccessful. Finally, it should not be forgotten that otherwise exemplary healing traditions can cause disease and injury (so-called iatrogenic medical problems) and these "losses" of an otherwise "scientific" medical tradition would have to be balanced with its gains in any strict accounting of its overall "success."

For these and related reasons, then, the conceptualization of an evolution of medicine proposed in this book should not be taken to imply progressive improvements in the handling of disease and injury. In fact I believe that there are

many practices and orientations in contemporary medicine that are biologically "unnatural," constituting medical maladaptations. An advantage of formulating medicine from an evolutionary standpoint anchored in human biology is that it serves to more clearly profile the good and the bad of contemporary medicine. My frame of reference and proposal is also not in any strong way a functional one. I certainly do not believe that there is a purpose, function, or design and direction that explains why and how evolution has occurred in medicine. These caveats about medical evolution as progressive and having taken place for functional reasons are consistent with contemporary thinking on social evolution generally.

Rather, the conceptualization I propose aims to depict what aspects of sickness and healing differ in the various types of societies that are held to form, in a rough way, a continuum of size and complexity and to have constituted, in an abstract way, probable phases in the posited evolution of society, however controversial and contested this area of study might be. I aim to show, in other words, how the construction of sickness changes in relation to changing levels and degrees of social organization; and similarly, how approaches to healing change as a result of these types of social changes. In addition to describing sickness and healing in different types of societies, I attempt to explain how transformations in the configuration of sickness and healing might be presumed to have taken place. My aims, in short, are to offer a descriptive interpretation of the evolution of medicine, to provide a conceptual frame of reference for visualizing this evolution, and to propose a methodology for studying it.

It is important to emphasize that I identify my effort as an introduction. I see it as pointing the way toward a more theoretically integrated conceptualization of medicine. My approach is to use basic knowledge of disease, injury, and the social aspects of medical care to provide a better way of looking at how medicine as a social institution arose, unfolded, and transformed itself during the course of human evolution and history. I believe that this way of conceptualizing medicine provides a useful frame of reference from which to examine practical matters pertaining to medical practice and care and theoretical ones pertaining to the social sciences.