9
A Broad View of Medical Evolution

Thus far in this analysis of the evolution of sickness and healing emphasis has been placed on features of the SH adaptation. It has been described as an amalgam of cognitive, perceptual, sensory, and physiological processes and mechanisms that are under genetic and cultural control and that enable individuals to understand and communicate the effects of disease and injury. The SH adaptation connects with and realizes a suite of medical memes, units of cultural information that are stored in the brain, the products of which "communicate" to the self and comembers how one is ill, what it means to be ill, and what can and should be done about it. From a developmental standpoint, the SH adaptation "uses" the information provided by society and culture "in order to" render sickness and healing meaningful to the self and interpersonally. When shared with members of the society, the products of the adaptation constitute medical institutions and form patterns, parameters of sickness and healing, that were discussed in an earlier chapter.

Sickness and healing, however, as previous chapters have illustrated, consist of a great deal more than the SH adaptation. They are quintessentially social and cultural constructions that are the core of medicine considered as a social system of a society. In other words, while the SH adaptation undoubtedly provides the material that is used to construct specific medical episodes of a society, medicine also has a societal dimension. Medical knowledge, procedures, social practices, and associated phenomena can be viewed not only as organizing a specific eventuation of sickness and healing but also as having a structure and constituting an organization of the society as a whole. This is certainly less evident in the case in smaller-scale societies and most prominent with respect to the later phases of the evolution of sickness and healing.

When pictured in a broad societal way, medicine could be said to represent a system of the society. This could also be described as the medical "Institution," with a capital "I," because this term with a lowercase "i" was used in a previous chapter to refer to shared products of memes. In contemporary societies, for example, the medical organization consists of numerous professions, educational establishments, and shared practices and rituals that make use of stored, ever-growing bodies of acquired scientific information about disease and injury. Medicine is also an industry of a society, an industry, moreover, that is connected politically and economically to a host of other industries that support, regulate, and in many ways exploit it. In this extended sense, one can speak of "social systems of medical care that have evolved ... conceived of as densely populated networks of heterogeneous arrangements and dependencies [which] include hospitals, pharmacies, insurance companies, governmental departments, university faculties, the multinational pharmaceutical industry [and] national regulatory agencies" (Bodewitz, Buurma, and de Vries 1989: 243).

In short, the SH adaptation might constitute the (biological and cultural) representation of the medical "in" and "of" an individual as expressed in episodes of sickness and healing, but this adaptation makes use of, realizes, and is variously controlled by knowledge systems and regulatory practices that spread across wide sectors of the society. In this broad and comprehensive sense medicine is linked, through information and material feedback loops, with other Institutions and organizations of the society.

Visualizing the Medical Institution of a Society

For purposes of illustration, one can describe the medical Institution of a society as consisting of five concentric circles (see fig. 1). As will be elaborated presently, the contents of any one of these circles depend on and build on the contents of those included within it. To this space of the medical are connected various nonmedical institutions or "stations" of the society that affect and are affected by what happens in the medical sector.

The three inner circles constitute the basic core of the medical and can be equated with individuals, average persons of a society. The kinds of diseases and injuries that a particular member of a society is prone to experience or undergo is one way of interpreting the material content of these three inner circles. Were one to visualize a very large pool of these "individuals," they would in effect describe the ecologically based and historically contingent epidemiological load of the population of a particular society. This way of conceptualizing the medical Institution will not be given attention in this chapter. It should be understood, however, that distinctive pictures of disease and injury realize the medical sphere of any particular type of society, as discussed in chapters 3 and 4.

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Figure 1.
Institutional Structures of Society

The three concentric inner circles are used to provide a descriptive picture of concepts used in previous chapters. The two inner circles describe the information, genetic and cultural, respectively, the products of which determine how disease and injury are configured and played out as sickness and healing in an individual of any particular society. The product of circles one and two is what is found in circle three, the SH response or behavioral output—a social construction or eventuality of sickness and healing.

Circles four and five describe not an average individual but an average society. These circles are thus equated with groupwide aspects of the medical Institution. Circle four is set aside for the society's parameters of sickness and healing. The overall style and cultural rationale inherent in the products of medical memes and institutions make up circle four. Circle five is set aside for the social groups, organizations, agencies, and material products of the medical Institution, all of which enable and in some respects govern the way sickness and

healing are configured and played out in a society. Each of these components of the medical Institution is taken up separately in what follows.

The Genetic Base of the SH Adaptation

The innermost circle in figure 1 can be equated with the strict biology of the SH adaptation, what was earlier described as embodying the medical genes. It refers to genetic information and programs sculpted by natural selection. In a linear causal chain of reactions, the effects or products of these genes constitute molecular biological structures, organs, physiological mechanisms, and processes that together make up the body and predispose it to and register the effects of disease and injury. This innermost circle of the medical space is fundamental in two respects: It constitutes (a) the genetic source of variation for vulnerability to develop and manifest disease and injury and (b) the biological material pertaining to the medical that is rigidly, genetically programmed and subject to natural selection by the environment. This inner circle can also be viewed as registering or tabulating the ultimate, genetic effects of cultural and social efforts directed to understanding and bringing about the prevention and control of disease and injury.

Much of the material of the inner circle is shared with the higher primates and was present in the phylogenetic line that led to Homo sapiens . Thus if one could project this inner circle across the purely biological/genetic phase of human evolution and examine its content one would probably find that it has not been subject to much expansion or variation. During the later phases of the evolution of Homo sapiens there obviously occurred major changes in the character of neural structures enabling language, higher cortical functions, and the character of human experience and behavior more generally. With respect to medical matters, such structures have been influential not only with respect to the signs and symptoms of neurological and psychiatric disease but also in ways of expressing disease and injury generally, as reviewed in an earlier chapter. However, fewer changes have taken place which affect the way other tissues and organ systems of the body are structured and function with respect to disease and injury (e.g., their composition, architecture, metabolism, mode of breakdown).

Since the evolution of Homo sapiens , still fewer changes have taken place. The material that regulates the embryology of the body and that leads to the formation of its anatomy, physiology, and biochemistry has simply not varied a great deal and is relatively resilient to environmental influences of all types. There are exceptions to this generalization; for example, during prehistory and historical time genetic vulnerabilities to infectious agents have probably changed, hemoglobin structures have changed in response to the prevalence

of mosquitos carrying the protozoa that can cause malaria, and the effects of anoxia at high altitudes have resulted in hematopoietic changes and more efficient ventilatory structures subserving respiration. Of course, some surgical modifications of anatomy and replacements of parts are now possible, but these obviously do not affect medical genes, and rendering them hereditable by means of genetic surgery or therapy is highly controversial. Similarly, although the number of physiological/chemical/pharmacologic interventions that can be brought to bear on the interior of the body and its mechanisms that are under genetic control is very large and seemingly inexhaustible, changes in the nature of how these systems actually unfold during development and come to be programmed and function have been limited, and to date it has not been possible to change the actual genetic systems that affect vulnerability to disease or modification of bodily manifestations of disease and injury.

The Cultural Component of the SH Adaptation

The medical memes make up the second circle of the medical Institution. As individuals during development learn what constitutes sickness and healing and come to store this information in their brains, their medical memes come to program the cognitive/emotional behaviors that together produce sickness and healing behaviors. These programs regulate visceral and cognitive systems that culturally express such things as pain, malaise, nausea, and lassitude so as to communicate sickness and elicit healing.

Circles one and two together, thus, describe the SH adaptation. Since this adaptation is constituted of medical genes and memes, a factor that underscores the connectedness between the processes of biological and cultural evolution, the two inner circles of the medical Institution are shown as open and thus continuous one with the other. Moreover, circle two is open and connected with circle three, which describes the actual product of the adaptation in behavior. In conscious, enculturated members of Homo sapiens there is held to exist no disjunction between, on the one hand, disordered respiratory and gastrointestinal mechanisms and functions and, on the other, the manifestations of this underlying disease and injury that contribute to shortness of breath, wheezing, nausea, and abdominal pain, as well as the associated ways in which all of the latter are expressed behaviorally, interpreted, thought about, and acted on (i.e., as culturally meaningful by the self and/or co-present group members) in eventuations of sickness and healing.

The integrated character of this product of genes and memes in the setting of disease and injury is why the two inner circles have to be formulated as open and connected one with the other: Genes and memes operate together to constitute the adaptation or mechanism that, in turn, produces sickness and

healing (see below). All of this underscores the fact that it is very difficult to conceptualize medical evolution with the genetic and the cultural components kept separate.

Compared to the innermost circle, the size and content of the outer, "second" one expands and changes considerably during social and cultural evolution. This is the case because cultural information in terms of which the SH adaptation is expressed accumulates and changes in content and organization during social and cultural evolution. As already mentioned, the variability in the way the SH response is understood, expressed, and "read" culturally, the semantic and existential interpretations of sickness together with the accompanying informational bases for routines and procedures of healing (i.e., medical memes), all have changed substantially and dramatically during cultural evolution, especially during recorded history. Thus, although the genetics of the SH adaptation, how it is materially formed and regulated, has changed very little during human evolution and history, the same cannot be said for its cultural counterpart. It has changed significantly, qualitatively and quantitatively.

The SH Response: Behaviors of Sickness and Healing

Circle three is set aside for the products of medical genes and memes, the contents of circles one and two, respectively. What sickness and healing "look like" in an individual, including its rationale, expressive meaning, psychophysiology, and symbolic form in behavior, are all represented in this third circle. It thus has to be represented as open to and connected with the units of cultural information or the medical memes of circle two that (together with the medical genes, the contents of circle one) produce the SH response. Enactments of pain, shortness of breath, nausea, and other manifestations of sickness, together with what they communicate and elicit from the self and others (i.e., their meanings and expressive content), all constitute examples of the material found in circle three. Because the symbolic form of the behaviors that comprise sickness and healing has changed greatly during human evolution and history, the size of this segment of the medical Institution is expansive and viewed across individuals of any one society is highly variable.

Although cultural aspects of sickness and healing, the contents of circles two and three, would appear to have comparatively few semantic and symbolic limits, one could also and in some respects probably should view this interpretive sphere of SH as limited with respect to space and content. This is so because, as shown in chapters 7 and 8, event the more culturally expressive aspects of the SH adaptation could probably be described as consisting of permutations and combinations of a fixed number of fundamental concepts and experiences (i.e., products of elemental medical memes, but requiring medical

genes) that pertain to the effects of disease and injury and that express sickness and healing in any particular social cultural context. Nevertheless, because it is important to emphasize the changing character of sickness and healing during the evolution of medicine, it is best to depict circles two and three as expansive and variable in size.

The Institutional Components of Medicine

The fourth and fifth circles together refer more properly to the groupwide characteristics of the Institution of medicine. These circles are equated with average, whole societies rather than with average eventuations of sickness and healing as was the case for the three inner circles. Pictured diagrammatically, the space contained by the two outer circles of the medical Institution has expanded considerably during cultural and social evolution. While both of these outer circles together are held to form societywide characteristics and to demarcate sociological components, they are distinguished on analytical grounds.

The fourth circle in the diagram designates the parameters of sickness and healing discussed in chapter 7. The space of this circle describes the overall style and pattern inherent in the way sickness and healing are configured and played out in a society. A society's parameters vary not only in content but also in heterogeneity, with more complex societies incorporating various traditions and models of sickness and healing. Hence this variable of homogeneity/heterogeneity would need to be represented in the diagram. Circle four is shown as open and connected to the preceding circle because the culturally expressive part of the SH response, that which more elaborately describes the social/cultural construction of sickness and healing in individuals, feeds into, reflects, and draws on the parameters of sickness and healing of the society as a whole; and vice versa. As was described in chapter 7, in each type of society the knowledge base, expectations, and rules that affect how sick persons behave when ill and how they relate to the group and to healers differ, as do the rules organizing the social practices of healing. Thus products of medical memes, when visualized as shared among members of a society, are what give sickness and healing in that society its distinctive overall character. This point can be stated differently: whereas circle three might denote the appearance of a particular "tree" of the medical Institution, the fourth circle denotes the whole "forest" of trees that make up the medical Institution.

The fifth and last circle of the medical is set aside to draw attention to the more structural, corporate, organizational, and material component of medicine. The group of kinfolk that helps manage sickness in Lower Zaire, and the institution that regulates all of this, would be located in this circle (Janzen 1978a). The group of villagers coming together in the Sepik society described by Gilbert Lewis (1975) which focuses on the sick person, which seems motivated

by concern, and which shares rules of behavior aimed to deter blame for sickness could also be "located" in this fifth circle of the medical however much its informational basis constitutes a part of sickness and healing it might seem to be. Finally, in this last circle one would find the paraphernalia, associated rituals, and social groupings (e.g., corporate associations) among healers as well as the available medicines, tools, and technical procedures used in healing.

As implied earlier, this fifth sector of the medical Institution is difficult to delimit. There exist many institutionalized practices and man-made objects including medicines and instruments that in some ways are part of the Institution of medicine and would need to be included, yet in other respects they are so far removed from actual episodes of sickness and healing, and under the influence of political and economic factors, that it might seem best to handle them as separate or "nonmedical." To say this is but to affirm again that where the medical ends and its dependencies begin is difficult to specify; and that some imprecision in placing boundaries of concepts is to be expected.

At any rate, a delimited sector is presented in the diagram for analytic and aesthetic reasons in order to describe the part of the medical Institution as a whole that is not exclusively or explicitly tied to behaviors composing sickness and healing but that nonetheless shapes, constrains, enables, and contextualizes them. This space is rendered as continuous with the previous one designating the parameters of sickness and healing. This is the case because the corporate medical structures and physical products of a society impart a distinctive cast to how sickness and healing are configured and played out in a society at large, and traditions about the latter also influence how the medical structures are made to operate. Here, as in any other two contiguous regions of the medical Institution, there exist reciprocal dependency relationships.

In modern societies the corporate, structural part of the medical Institution is very complex. It is made up of such things as learned/scholarly/scientific knowledge structures, technical procedures, and associated physical provisions; knowledge, routines, and resources of "alternative" medical traditions of the society; professional bodies and their rules of operation; institutions involved in the teaching of medicine and nursing; political economic constraints and directives that support practice arrangements; and associated influences from external institutions that structure how medicine is practiced. In brief, the outer circle of the medical encompasses all those structures that render the medical a large corporation and megaindustry that is fed, regulated, and exploited by other corporations and industries of a society.

The two outer circles that comprise the Institution of medicine in effect feed information and material to the three innermost circles (which describe individual eventuations of sickness and healing). As will be elaborated presently, the corporate part of the medical also feeds and receives information and material from the other institutions of the society that in turn will alter parameters of sickness and healing and, ultimately, affect how sickness and healing

are to be regulated and shaped. The continued growth and expansion of the medical Institution, especially the fifth circle designating its corporate superstructure, is what poses a powerful challenge to one seeking to understand the direction and end points of the evolution of sickness/healing and medicine.

Control and Regulation of the Medical Institution

Completing the illustration of the medical, one can note by inspecting figure 1 that the concentric and open circles that constitute medicine in its entirety are connected to a series of stations. The latter correspond to nonmedical institutions that together describe a whole society from a macrosociological frame of reference. These institutions regulate behavior involving such things as spiritual/religious, political, legal/jurisprudential, economic, social welfare, and leisure concerns.

Each of these separate but integrally connected (to each other and the medical) institutions furnishes inputs and receives outputs from the medical. All are interdependent, and happenings in any one institutional sector can reverberate throughout the network of connected organizations. This has been reviewed in earlier chapters. For example, in Zinacantan, Mexico, the political organization of the community that included the Hiloletik (i.e., native shamanistic healers) as revealed during the annual ceremonies appeared to rank individual healers and this seemed to qualify their repute, affecting tendencies of villagers to seek healing (Fabrega and Silver 1973). In Zulu medicine, as beautifully described by Ngubane (1977), the fees charged by diviners are set with respect to the techniques used and the social ranking of the diviner. Here, then, seemingly political groupings and functions and economic factors have an influence on the way healing was carried out. During the medieval period of Europe, as an example, the Christian church played a very important role in how disease* was defined and conceptualized and healing was carried out (i.e., the practices and materials of healing) and hence happenings in the religion institution affected the medical, and vice versa. During the modern and postmodern European phase of medical evolution the influence of the religion institution has all but been eliminated (at least from the biomedical sector) and the legal/governmental and the political/economic institutions have assumed dominance, for these dictate what sick persons can expect and what healers are allowed to do.

In each of these instances, then, corporate, organizational, and material factors pertaining to nonmedical institutions directly influence circle five of the medical, its corporate/organizational sector, and through this effect also influence and constrain the form and style of sickness and healing (i.e., the parameters). The informational aspects of the way all of this is realized is ultimately

represented in how individuals behave, which means that the information is stored in the brain as medical memes. These examples illustrate the reciprocal relations between the nonmedical and the medical institutions. Political economic and governmental developments in contemporary America are increasingly influential in how practitioners orient and conduct practice and also how wouldbe patients behave in a setting of sickness. Hence, by today's standards of operation, these nonmedical institutions would have to be described as strongly linked to the medical.

In conceptualizing the evolution of medicine as a major Institution of society, I am attempting to depict the more or less systematic changes that have taken place in the way sickness and healing are configured in light of relations among the various other major institutions of society. The diagram reviewed previously provides an illustration of the five interrelated layers of the medical Institution that are implicated in these transformations as well as (some of) the various nonmedical institutions that are dialectically related to the medical during phases of evolution. Obviously, each of the institutional sectors of society can be assumed to be undergoing change in association with changes in medicine. Implicit in my conceptualization of this intellectual problem is that as sickness and healing come to be configured differently during social evolution, society as a whole, along with other nonmedical institutions, is also undergoing evolution.

Stephen K. Sanderson (1990, 1995a, 1995b) offers an excellent analysis of the topic of social evolution and transformation. Factors that are thought to have played a major causative role during these transformations as well as features of society that undergo quantitative or qualitative change are summarized and discussed critically. Notably, archaeologists, anthropologists, and sociologists who address this problem area as a rule do not discuss medical phenomena per se (for exceptions, see Cohen 1989 and also chapters 1 and 2 above). In Sanderson's three books, he reviews the typologies that have been used to depict stages of social evolution. I have used one such typology in my discussion of the evolution of sickness and healing, namely, that of Johnson and Earle (1991).

The general topic of social evolution, its phases and its dynamics, has a long history in the social sciences and is very complex and highly contested. Even a brief discussion of this topic in relation to the evolution of medicine is well beyond the scope of this book. Suffice it to say that in conceptualizing the evolution of sickness and healing (and the medical Institution of a society), I am of necessity putting aside the complex set of evolutionary changes that are taking place in the society as a whole, changes that are causative of, reactive to, and certainly complementary to what is taking place with respect to sickness and healing. For a summary of these issues, the reader is referred to the publications of Sanderson. Figure 1, above, and variants of it that appear later in this chapter propose a way of drawing attention to a small portion of the relatively com-

plex set of changes encompassed by social evolution, namely, those related to medicine.

The Medical Institution Viewed in Terms of Units of Information

A diagram of the medical Institution can be conceptualized from the standpoint of the units of information, the products of which make up and feed into the various circles that constitute the medical. Each circle incorporates and symbolizes the information of those contained within it. The inner circle is composed of genetic information, namely, the part of the genome that programs the apparatus of the body and that furnishes the capacity to become diseased and injured, and which is subject to natural selection. The second circle of the medical contains the units of cultural information that program sickness and healing. Four things need to be kept in mind about these medical memes: (1) their products inform about disease/injury, thus having (2) effects on the self and social environment that (3) elicit self-behaviors and responses from conspecifics aimed at understanding and neutralizing disease and injury and, eventually, (4) feeding upon and leading to innovations in ways of handling sickness and healing—eventually, to inventions, technologies, agencies, and social dependencies. Hence the eventual anatomical and physiological products of medical genes serve as templates for the registration of disease and injury and during development connect with the contents of circle two; the memes of this circle, in turn, produce the SH response of an average person, circle three; and the memes of circle three when examined in terms of their overall stylistic properties, societal characteristics, and material products are found in circles four and five. Finally, happenings in circle five, ultimately regulated and sustained by products of medical memes, affect and are affected by products of nonmedical memes that in effect are what steer and regulate nonmedical institutions.

Most fundamentally, and as elaborated in the previous two chapters, the products of medical genes and memes represent and inform about a condition of disease/injury in informational terms, thereby constructing a sickness/healing routine or ensemble that communicates about its nature so as to elicit efforts at prevention, alleviation, undoing, and, if necessary, resignation to death with attendant preparation for this outcome. I am here emphasizing that the whole medical Institution is a product of, connects with, and is geared to the material substance and behavioral expression of the SH adaptation in sickness and healing, the contents found in the first three circles. There are obviously big distances and logical jumps between genetic programs, pure physiological manifestations of disease and injury, biocultural expressions of this in the form of sickness, "natural" or highly elaborated healing responses from persons of the

social environment, social groupings and their modes of operation that organize how sickness and healing are structured, and dense networks of agencies and dependencies that regulate or exploit medicine. The concepts introduced in previous chapters and the frame of reference that was outlined when represented as information constitutes a way of analyzing medicine holistically.

Circle four and especially circle five, then, contain the products of medical memes that involve groups, corporate structures, and material/technological objects, all of which affect how sickness and healing are carried out in a particular society and all of which embody cultural information. How these social practices and arrangements and the man-made objects of medicine are used is influenced and regulated by products of other items of cultural information of the society that reflect political, economic, religious, and jurisprudential concerns. The effects of some of these "memes" might well filter down and come to shape events of sickness and healing and would thus qualify as medical memes, in the sense in which this concept has been defined.

How the Organization of Medicine Changes during Evolution

In contemplating the evolution of medicine as an Institution, each of the previous five compartments of the medical could in theory be expected to change in quantitative size, qualitative content, and (all except the first) in its relations with those medical compartments that are inclusive to it. Furthermore, and as I indicated earlier, since the medical Institution is but one member of an integrated set of major institutions that describe how the society operates and functions—a society that also evolves —the kinds of nonmedical institutions that become influential in medicine during different phases of social and cultural evolution differ and change. With all of this one also finds changes in relations between the medical Institution and nonmedical institutions. All of this would need to be taken into account in a broad description of how medicine evolves and is depicted diagrammatically. Given the modest goal of this book, which is to provide a frame of reference and a methodology for conceptualizing the evolution of medicine, all of the preceding types of changes cannot be fully covered. I will limit myself to just a few summary comments.

In prehuman groups all of the circles of the medical, especially even circle one, come into existence and begin to expand. The machinery for the SH adaptation becomes defined. Similarly, it is during this late phase of the evolution of Homo sapiens that medical memes, the contents of circle two, become defined, elaborated, and relatively focused on the body and the self and become connected with medical genes. The same is obviously true for circle three, which contains the SH response of sickness and healing. Another way of conceptualizing this is to say that although most of the structures and physiological sys-

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Figure 2.
Medicine in Family-level Societies

tems that rendered pre- and early human groups vulnerable to disease and injury were similar as compared to other higher primate groups, the capacity to understand their implications and respond adaptively is posited to have evolved during this earliest stage of human evolution, and this would be marked by the emergence of the various circles that describe the medical Institution.

In family-level groups of Homo sapiens circle five of the medical diagram, which describes what was termed the corporate, organizational component, would be very small (see fig. 2). There is little that one can point to in these types of societies that qualifies as a separate medical corporation or organization. Sickness and healing are family and group concerns (among the !Kung Bushmen, at least, medical ceremonies are for the benefit of all and seem to have more than just medical purposes; see Marshall 1969), there is little differentiation of roles, little in the way of specialized resources and techniques, and (as described by Holmberg [1969] for the Siriono, at least) a passive, fatalistic resignation seems to often prevail in the setting of a serious, protracted sickness and healing ensemble.

Similarly, the level of definition, if not the actual existence, of outer, separate, nonmedical stations connecting with the medical (i.e., denoting the separate institutions of a society) would also be difficult to depict diagrammatically. This is so because in family-level societies one does not find clearly articulated institutions, and sickness and healing and the medical in general are not easily discriminated from deliberations and actions of political, spiritual, and economic import. During this early stage of evolution, medicine cannot be said to have its own corporate/Institutional identity, and it is very difficult to establish that deliberations pertaining to disease and injury are not also conceptualized and handled in terms of other, "nonmedical" concerns.

Distinctive kinds of disease and injury reviewed in chapters 2 and 3 would constitute one way of depicting the material in the three inner circles of the medical. It is very likely that the epidemiological profile of early human, family-level societies was similar to that described for prehuman groups. With respect to information and behavior, the size and relationship between the circles would have to be depicted in such a way as to represent the accommodation and balance that has been reached between the processes of biological and social evolution of medicine.

Compared to more complex, evolved socleties, the cultural part of the medical (depicting the largely expressive and sociologic features of the SH adaptation) would be comparatively underdeveloped. Little in the way of specialized knowledge and resources pertaining to sickness and healing has accumulated, nor have individuals evolved scripts in terms of which they can manipulate others through sickness and healing, either as "patients" or as healers.

Sickness and healing during this phase of evolution reflect most nearly the complementarity among systems descriptive of the human organism. A holistic, biocultural, somatopsychic, and psychosomatic unity characterizes an organism's responses to disease and injury. Moreover, what natural selection has sculpted as an SH response reflects interdependency among group members, runaway social competition with other (prehuman and nonhuman primate) groups, and stringent living conditions. On the one hand, the social environment plays an important function in the way the SH adaptation has been designed, is communicated, and is dealt with; on the other, the individual has evolved so as to configure and play out sickness and healing in a way that balances individual needs with group needs. Although some routines of sickness expression have evolved along with medicines and procedures so as to more effectively cope with disease and injury, these are relatively few in number and exert but limited effects; and although individuals expect help from comembers, imperatives of the group and bare subsistence living render SH deception or exploitation unrealistic, unprofitable, and unacceptable.

For these and other reasons, then, the three inner circles depicting the medical in the diagram should be conceptualized as openly connected with each other and relatively closely placed one to the other and in relation to the fourth

circle, denoting the parameters of sickness and healing. This is a way of diagrammatically showing that, compared to more complex societies, in these elementary ones the process of social evolution has not as yet exerted much influence on the way the SH response can be played out behaviorally.

Compared to individuals of family-level societies, the general health of members of village-level, chiefdom, and prestate societies is generally regarded as lower due to dietary and nutritional deficiencies, with consequent greater and different vulnerabilities to infections that are transmitted from contaminated foods and objects. Thus some of the material content "inside" the three inner circles of the medical would clearly need to be depicted as different, in an epidemiological sense, accounting for the different mix of infectious diseases and higher general levels of morbidity that are found.

A difference in epidemiological material is complemented by a difference in the sheer construction of sickness and healing because of sedentarism and the increased complexity in the society. To recall, knowledge of and resources for sickness and healing are more elaborated and hence the way the SH adaptation is realized is more varied and complex. This would translate as a larger space and more diversified content that would have to be depicted in circles two and three. The contents of the fourth circle would conform to the parameters of sickness and healing described for village-level and chiefdom/prestate societies in the previous chapter and would likewise (compared to family-level societies) reflect a more varied, elaborated character. In other words, since the patterning of these general aspects of sickness and healing differ from preceding societies, with greater complexity and differentiation evident, the specific area set aside exclusively for circle four would have to be expanded compared to previous social types.

Societies at this level of evolution possess rudimentary forms of what one can term a medical corporation or institution. Consequently, the actual definition and size of the fifth, outer circle of the medical Institution expands and exerts a more distinctive influence on the four inner ones than was the case in prehuman and family-level societies. For example, specialization of practitioners is found in some prestates and healers often show the beginnings of corporate structures. Family management groups are often more influential and institutionalized, and these also would belong in circle five. Furthermore, political and religious concerns, although potentially related to concerns of sickness and healing, are more autonomous, self-sufficient, and explicitly handled than in previous societies. In other respects as well, what one could think of as nonmedical institutions begin to be differentiated. Certainly this is the case for the spiritual/religious and the political but not the legal/jurisprudential, although that one finds more explicit rules and procedures for the resolution of social conflicts is clear. Consequently, in the diagram depicting how these societies operate and function from a medical evolutionary point of view, the outlines that define at least some of the nonmedical stations that "connect"

with the medical would need to be enhanced. In eventuations of disease and injury one begins to be able to distinguish, however imprecisely, how activities that have explicit medical, political, economic, and spiritual significance interact.

In these societies, moreover, it begins to be very difficult to provide an average, unitary representation of the first three segments of the medical, the ones that have been held to arbitrarily "contain" the biological and cultural programs of the SH adaptation along with the SH response itself in the average individual. This is so because it is difficult to picture a "typical" eventuation of sickness and healing in any one society at this comparatively higher level of complexity. What one finds is that any one instance of sickness and healing in a particular individual begins to be configured differently from another. This is so because medical events take place and are played out and handled within diverse subgroups and subcommunities of the society. The latter split and segment the society in a complex way. Any two random SH responses taking place in this type of society begin to elicit very different experiences, cognitions, and behaviors because their social and cultural location in the society could differ substantially with respect to kinship structure, lineage lore, rituals, knowledge, and resources. Different sets of attitudes, beliefs, and orientations pertaining to sickness and healing would be involved, depending on the person's social background and access to resources.

These societies would have to have the space of the three outer circles of the medical diagram expanded. For one, more knowledge is available about sickness and healing. This essentially translates as what persons who are sick are able to communicate about disease and injury and how the resulting "messages" or constructions of sickness and healing are capable of being understood and acted on by comembers (e.g., knowledge about bodily anatomy and function and knowledge about medicines and technical procedures). An additional common factor that would account for the greater importance of the outer circles of the medical during this phase of evolution is that the more complex social environment of these societies allows individuals to begin to effectively exploit sickness for individualistic needs; and conversely, specialist healers become differentiated and they gain an ability to manipulate and exploit sickness for their own or their subgroup's needs as well as on behalf of sick comembers. In short, circle four would depict a more diversified design (to account for complexity and heterogeneity of the parameters) and circle five a larger, better-defined outline (to account for the presence of structures, organizations, and elaborated material products).

All of this could also be visualized diagrammatically by recalling that during this phase of cultural and social evolution certain nonmedical, "external," and separate institutions begin to exert a determinate influence on how sickness/healing eventuations are constructed and played out. The arrows connecting certain nonmedical with medical institutions (e.g., the religious and

political) would have to be depicted as heavier and more influential. Thus varieties of sickness conditions and their associated causes are likely to be formulated and interpreted in terms of current and past political happenings occurring within and between lineage-affiliated and segmentary groupings. The consultation by a specialist outside healer could also be said to constitute a discernible political input into the medical, as Ngubane (1977), for example, informs about the Zulu. Medical memes developed in one lineage might be imported into another, with a host of political economic implications linked to obligations based on conventions about social exchange and reciprocity. Interpretive schemes and narratives of medical affliction in any one group will naturally expand and become more complex as knowledge structures and social practices pertaining to sickness and healing in a neighboring group or allied lineage grouping are borrowed, expropriated, or simply modified and neutralized.

In societies at this level of evolution that are more centralized and unified, the beginnings of an official, usually sacred version of social order and the justification of norms are found. Such an ideology or religion has obvious medical overtones; it will set reference points for interpretations and contribute some standardization to the way sickness and healing are configured and played out. A more or less standard ideology about sickness and healing can challenge and undermine locally contextualized interpretations, imparting some complexity and positiveness, if not official formality, to how the medical is structured in the society. In the event, sickness and healing configurations could be said to constitute part of an expanding social consciousness about the sacred and secular, a consciousness that begins to distinguish between happenings in separate areas of life (institutional sectors) and between the implications that sickness and healing might have as a consequence of social/political as well as moral considerations (e.g., as devolving from the social standing of the person ill). All of the changes described here would in effect begin to more sharply define what has been described as the outer nonmedical stations of the society.

Essentially all of the changes described for the two previous types of societies are accentuated and more pronounced in societies categorized as states and especially empires and civilizations (see fig. 3). This involves in particular (a) pictures of disease and injury, with chronic diseases and disabilities more common (as a result of changes in the ecology and social structure) and also outbreaks of new disease pictures and epidemics as a result of contact with geographically separate societies, (b) the influence of accumulated, literate bodies of knowledge of sickness and healing which greatly complexify medical understandings and behaviors and serve to in part standardize the cultural expression of sickness and healing, (c) the growth of medical "professional" and ancillary corporate structures (e.g., those involved in the invention of medical procedures and the manufacture of special herbs) as well as nonmedical institutions, and (d) the capacity of individuals and different separate groups within

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Figure 3.
Medicine in Civilizations and Empires

a society to gain power over how sickness and healing are to be played out (e.g., the degree of control as well as social exploitation that is possible for the SH response, regardless of whether one considers its sickness or healing realization).

These types of societies contain separate, well-defined corporate groups, estates, and institutions, and one of these (or a cluster of them, given that different doctrines and traditions pertaining to health are found) can properly be considered as truly medical. These societies are often described as feudal, oligarchic, or "aristocratic" to denote their special combination of particularism (as applies with respect to family-level, village-level and chiefdom/prestate societies) and universalism (as classically applies to modern and postmodern European societies). In other words, individuals are aware of belonging to a specific group or estate (hence their particularistic identifications) as well as "fitting into a universal order of society" (Unger 1976: 148).

For the reasons just discussed, the institutional/corporate sector of medicine, the fifth medical circle of the diagram, would need to be described as well defined, very large, and diversified. Its relative size would naturally expand

considerably. Healers are socially differentiated and calibrated as to learning, repute, experience, apprenticeship, specialization, expense, and morality. Family management groups become necessary to negotiate between systems of care that are available. Industries for the manufacture of medicines and sickness/healing paraphernalia of all types become established. The influences of the corporate segment are mirrored in the distinctive parameters of sickness and healing described in a previous chapter. Sickness and healing become more secularized, scientific, and focused on bodily and behavioral manifestations; yet this expanded emphasis on well-being and health continues to have spiritual, moral, and psychological as well as bodily dimensions.

It can arguably be asserted that the strong effects of these corporate, organizational, and material features that serve as quasi standards for the medical (found in circle five) on the contents of circles three and two are unique in the social evolution of medicine. Whereas during earlier phases, the contents and products of memes reflected a balance between individual (disease/injury) centered changes and cultural (spiritual/existential/moral) concerns, during the empire/civilization phase ideological and especially political economic imperatives become highly influential. Similarly, organizational/administrative influences (e.g., municipal or more regional in some states, involving literate, academically trained practitioners in others) begin to play a role in shaping the configuration of sickness and healing. This would show up on a hypothetical medical diagram as expanded material and diversity of content and organization in circle four and especially circle five of the medical Institution.

All of these diagrammatic conventions would symbolize how the Institution of medicine, considered almost as an organization of the society, comes to exert its influence on configurations of sickness and healing. And the latter, to be sure, would be very differently constituted in different sectors of society given its larger size and complexity. Stated briefly, official, scholarly, and either secular (China), sacred (India), or more balanced (Galenic Mediterranean, medieval Islamic) literate traditions of medicine will dominate and strongly influence the SH response by feeding information, material, and expertise that affect how sickness and healing are configured and played out in the many separate ethnic, religious, and social economic groups of these societies, many of which have their own "small" tradition that exerts its own influence. Most, if not all, of the different types of social groups can be expected to subscribe to a folk, indigenous sickness/healing tradition that often functions in opposition to the scholarly, "scientific" one. Moreover, a group can borrow freely from another group's tradition and from the more or less standard, official, literate, and formal one, that is, the "great" tradition.

The large and complex corpus of information, technical resources, and social practices constituting the corporate institution and organization of the medical Institution (the fifth, outermost circle of the diagram) is balanced by the greater definition and influence of nonmedical institutions or stations of the

society. Moreover, in states and especially empires/civilizations, the manufacturing, commercial, fiscal, and administrative/regulatory institutions would need to be better defined in the medical diagram than in the less evolved societies, where it was the political and religious institutions that were important. Money payments—to healers and to their assistants for specially prepared herbs, procedures, and complex paraphernalia—now punctuate sickness and healing enterprises. Political and legal/jurisprudential institutions (at least in early modern European societies) begin to regulate and monitor the conduct of sickness and healing. All of these influences, which originate in nonmedical sectors and come to structure the organization of the medical Institution, necessarily influence how sickness and healing are configured and played out in these societies.

The diversity of material and information supplied to the medical Institution by nonmedical institutions constitutes a basic reason why the features of the SH response (the contents of circle three) would need to be depicted as more heterogeneous, more differentiated, and more secularized in the medical diagram of states, civilizations, and empires. In these societies the flow of material and information from outer, nonmedical stations strongly influences circles five and four, and some of it comes to constrain how the SH response is realized (circle three), ultimately coming to be represented in circle two as medical memes.

Developments taking place in societies associated with the later two phases of the evolution of medicine, those termed modern and postmodern , are illustrated in figure 4. Medicine in these societies naturally involves major changes in the corporate organization of medicine and in the macrosociological architecture of society. But also as a cultural tradition, biomedicine is associated with sharp differences in the way the various "inner" components of the Institution of medicine operate and function with respect to the configuration of sickness and healing. The changes taking place during this phase of social and cultural evolution all reflect, at the minimum, the hardening of secularization, the expansion of scientific knowledge, and the growth of industrial capitalism. They can be equated with the psychological, social, political economic, and jurisprudential transformations associated with modern, liberal, and contemporary, postliberal societies (Berman 1983; Giddens 1984, 1990, 1991; Unger 1975, 1976).

That biomedicine develops a formal, legally official status in the society has several implications. It means, in effect, that all that passes as medically or "clinically" valid must correspond to how the body operates and functions given the biomedical calculus. Now, all "major" traditions of medicine, and many "perhaps even all" of the "minor" ones as well, posit forces, substances, and structures inside the body. However, biomedicine is different. First, it operates in terms of physical anatomical structures and physiological and chemically specified systems and generally this is not true with other traditions of

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Figure 4.
Medicine in Contemporary Postmodern Societies

medicine the anatomies of which are thought of as analytical, functional, and perhaps even metaphorical and the ethnophysiological mechanisms are not always quantified and measurable (although that they can achieve a high degree of specificity is clear, as for example with moxibustion and acupuncture sites in Chinese medicine and specially prepared herbs and foods in Aztec and Ayurvedic medicine). Second, with respect to sickness and healing and compared to other traditions of medicine, biomedicine operates in terms of a highly elaborated, technically based corpus of information about the body and behavior. The scientific understanding of disease and injury (and sickness and healing) may constitute cultural knowledge and is a product of cultural evolution, as is the case with other traditions of medicine. However, its social consequences for the way the institution of medicine operates and functions, as discussed in earlier chapters and now visualized diagrammatically, need to be fully appreciated.

In terms of the conventions of the diagram, the comparatively more elaborated "knowledge structure" of biomedicine would be represented as an expanded second circle. Stated baldly, individuals and healers all have more memes with which to understand, play out, interpret, and respond to an event of sickness and healing.

The fact that in this tradition of medicine there exists a very high correspondence between the anatomical, physiological, and molecular understandings of disease and injury (products of circle one), on the one hand, and how sickness and healing are configured, carried out, and actually validated in the society, on the other, would need to be represented in the diagram in some fashion. As an example, what one ordinarily thinks of as the symbolic and figurative material of circles two, three, and four (during earlier phases of social evolution) would need to be visualized as reflecting the impersonal, universalistic, mechanized operation of agents, processes, and forces programmed by genes that bring about an event of sickness and healing. At the very least, the sheer number and organization among medical memes would reflect a complex, hierarchical order consisting of physically layered and interconnected systems. Such an organization of memes is not only reflected in the "storage bins" of the brain but also, through their products, as shared in the society, in the way details of sickness and healing are structured in physical settings (e.g., medical versus surgical clinics), types of relations (e.g., medical specialists, holistic medicine practitioners) and in corporate organizations (e.g., specialist professions, types of supporting medical technologies).

In none of the other traditions of medicine (either "major" or "minor") has a condition of sickness required technical validation, nor have the resources of these traditions enabled practitioners and society to objectively measure and quantify sickness and healing. Yet in traditions governed by biomedicine, technology and physical procedures involving equipment and specialized tests of chemical reactions, all of which are held to provide "objective" information, are used to actually render valid and real what in other societies are highly emotive, socially elaborated, and existentially referenced states of suffering and distress.

In all societies, of course, the identity given to a sickness and healing ensemble is culturally determined and, in this sense, validated. However, as reviewed earlier, the facts of illness, suffering, and sickness itself have constituted prima facie evidence of a medical problem. Thus, whereas in other traditions of medicine personal statements about the self and body and social judgments pertaining to behavior and experience constitute the "gold standards" about sickness and healing, in contemporary societies this function is performed by machines and "experts" of many types, not just healers and certainly not sick persons. This correspondence between the description of the SH response and the parameters of sickness and healing (and the actual workings of medical corporations and nonmedical institutions) might be represented diagrammati-

cally by expanding and more openly connecting circles three, four, and five of the medical diagram and by opening them to the memes of political and economic institutions.

To reiterate this point, in all types of societies there exists a correspondence of sorts between how each of the sectors that comprise the medical is articulated and played out. What distinguishes medicine in the later phases of evolution presently under review is the technologically explicit and detailed way in which the inner circles are delineated and codified, on the one hand, and the determining influence that the material identified in them and the procedures used to measure them have on how sickness and healing are constructed, managed, and processed as socially valid enterprises of the society, on the other.

The corresponding changes in the institutional and organizational aspects of the medical are equally striking. For here, as social theorists have suggested, one finds an effacement of the boundaries between the various corporations and institutions that make up the society (Giddens 1984, 1990, 1991). A merging of state and society is said to take place. The state and its associated influences on other institutions of the society feed and virtually control establishment medicine: public, administrative, and legal directives and rules of the society have an impact on those directives and rules that provide a major rationale of biomedical practice. Scientific and technological institutions outside of medicine become highly influential, not just the political, economic, and commercial ones that operated in civilizations and empires discussed earlier; and technical/expert information germane to these institutions influences how individuals explain their body and its changes during disease and injury. Similarly, the products of service/leisure institutions are communicated in increasingly intrusive ways so that they also come to make up part of every individual's concerns about the body, the self, and health. While all of these nonmedical institutions are separated and somewhat self-governing, hence should be depicted as diagrammatically discrete and autonomous, they are reflexively influential on the individual in a mediated way and thus would appear to be incorporated in the medical memes in the brain, governing preoccupations about health and well-being of individuals of modern and postmodern European societies.

It follows that the sharp boundary that separated the medical from the external, nonmedical stations in the macrosociological diagram of states and civilizations would in some respects be much less visible in the medical diagram of modern and especially postmodern European societies. In fact, it might be necessary to depict these nonmedical institutions as overlapping and continuous with the medical, or at least as connecting freely with it via informational and substantive flows.

This is a way of summarizing the reflexive, mediated impact that general, nonmedical expert/scientific systems, as well as those of other systems of modern society, have on human experience, including medical experience and practice. Although there exist immense differences between modern approaches to

sickness and healing and those of earlier societies, the easy traffic across institutional sectors that constitute modernity and postmodernity brings to mind the integrated character of social experiences and situations that is found in the more elementary societies. The difference, of course, is that whereas in elementary societies social experiences surrounding sickness and healing are integrated because the cultural information that creates them is judged as connected to the varied affairs of the group, in modern and postmodern ones the cultural information that creates social experiences is judged as particulate, differentiated, and centered on disease and injury, although relevant to and originating in the separated affairs of the society.

Social theorists (e.g., Giddens) point out that in modern liberal and post-liberal societies social consciousness and the self are profoundly modified by local and distal happenings as a result of rapid information flow and the merging of institutions. Since health and the well-being of the body as well as sickness and healing per se constitute major preoccupations of the self and the latter, in addition, is the focal target of equally compelling and regulative influences from other institutions that serve to promote reflexive monitoring through social mediation, one may begin to get a better glimpse of the complex way in which the many corporations of the society exert control over the configuration of sickness and healing.

Another way of conceptualizing the effect of modernity and its plethora of expert/technical systems on the conduct of sickness and healing is to concentrate on medical memes. In elementary societies, these are few in number and have polyvalent meanings and functions. An item of cultural information pertaining to disease and injury has many simultaneous meanings and implications that incorporate political, economic, and spiritual concerns. In more complex societies, in contrast, the number of medical memes increases and their meanings and functions are more centered on disease and injury. Whereas medical memes in the latter types of societies may have their origin in and repercussions on diverse settings and activities of the society, when brought to bear on sickness and healing their more general meanings and functions are suspended and focused. Yet on the other hand, the context, position, appearance, and manner in which disease/injury is played out as sickness/healing is profoundly influenced by (indeed, assembled and fabricated by) the nonmedical circles or institutions that now come to control sickness and healing.