Sociology of Health & Illness Vol. 36 No. 7 2014 ISSN 0141-9889, pp. 1116–1117 doi: 10.1111/1467-9566.12180
Revisionist or simply wrong? A rejoinder David Armstrong Department of Primary Care and Public Health Sciences, King’s College London, London, UK
It surely must please any author to know that someone has read their article, but to have a commentary, albeit critical, is a special accolade. So my thanks to Gilleard and Higgs for their time and effort. I think we are agreed that chronic illness is largely a 20th century phenomenon, that it appeared early in the century and grew to become the major morbidity problem it is today. Where we differ is in how this phenomenon is to be explained; and underpinning this disagreement lie our different approaches to what might be construed as an adequate explanation and to method. My article was descriptive in the sense that it tried to take contemporary observations (as recorded in the articles, reports, correspondence and editorials of JAMA) to reconstruct the changing perceptions of the nature of disease and its distribution during the 20th century. My ‘revisionist’ claim was that these changes in perception could account for the apparent growth in the prevalence of chronic illness without invoking a real or biological change in the form or distribution of morbidity. The latter explanations, in fact, emerged only towards the end of the century, well after the cognitive transformation had been accomplished. Why did these changes occur? I prefer to stay agnostic, in part because I am persuaded by Foucault’s (1980) advice to study power ‘where it becomes capillary’ (p. 96), where it has its immediate effects, and in part because I think the contemporary form of causal explanation is itself in need of understanding. For example, the medical shift to multi-causal (multifactorial) explanations of disease aetiology in the second half of the 20th century seems to reflect the same paradigmatic changes that accompanied the emergence of chronic illness. Gilleard and Higgs, however, propose causes as explanations, rather than constructs that themselves need to be explained. They claim, for example, it was the release of beds during World War II that triggered the interest in diseases of later life and it was the desire for higher status that led municipal hospital doctors to form the new specialty of geriatric medicine. We will therefore have to agree to differ on our forms of explanation though, if pressed, I would feel more comfortable in seeing it the other way round: that the new ‘reality’ of chronic illness required new methods of organising health care. Gilleard and Higgs remind us that there is already a body of historical literature for some of the topics I covered – particularly on the place of ageing in medical thought – that identifies debates centuries earlier. I think it is noteworthy that the ‘historical’ literature described in the commentary was all written in the latter half of the 20th century, well after the phenomena I was trying to describe had stabilised and become a part of everyday understanding. I tried to eschew this historical method as it seemed somewhat circular: once chronic illness had been identified in the 20th century it was possible to re-read or reinterpret older texts to identify its existence in the past. Instead I used a (sociological) qualitative method to analyse texts. These were not the transcripts of interviews, as my respondents were mostly long dead, but they had left their own words, as published in JAMA, for me to use in lieu of transcripts. I used Foucault’s analysis of the emergence of modern medicine as a starting point as it enabled me to situate the 19th century discussion of acute and chronic disease in JAMA; but otherwise my article is entirely concerned with what my respondents ‘said’ (or, more accurately, wrote) © 2014 The Author. Sociology of Health & Illness © 2014 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd. Published by John Wiley & Sons Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Maiden, MA 02148, USA
Revisionist or simply wrong? A rejoinder
1117
during the 20th century. None of them mentioned Galenic medicine or the concept of ageing in the early modern period. As in any qualitative analysis I have been selective in reporting from my texts and it is of course my interpretation. Yet if I am wrong in my interpretation then perhaps my respondents should shoulder some of the blame? When, for example, Hedley (1935: 1407) noted that ‘Deaths previously attributed to senility are now listed as heart disease’ was he, too, mistaken? Perhaps Gilleard and Higgs would argue that these commentators failed to see the bigger picture or were unaware of earlier historical debates (though, as pointed out, many of these debates were identified only later in the century). But using my method and my sources all I had to analyse was what my respondents reported and I had no evidence to suggest that they deliberately misrepresented the contemporary world as they saw it. Later in the 20th century, after the construct of chronic illness had materialised, it was possible to devise more elaborate explanatory frameworks involving supposed biological changes, such as Omran’s (1971) epidemiological transition, but my study was largely about that inchoate period before it stabilised. At times contemporary commentators seemed perplexed, at times they grasped for explanations, at times they disagreed. Many reported diagnostic relabelling, a not uncommon practice, as diagnoses often seem to come and go: dementia praecox, for example, an early 20th century diagnosis that once filled inter-war mental hospitals, has now disappeared. But JAMA writers also seemed to be coming to terms with the new idea of population morbidity. The classification of death (by pathological cause) emerged in the 19th century but the first tentative morbidity classifications were a 20th century invention – which can, in retrospect, be applied to earlier centuries. The idea of measuring morbidity in a population (rather than in hospitalised patients) emerged at the exact point that chronic illness or disease emerged from below the threshold of medical perception. It was the measurement of chronic illness in the community that underpinned the inter-war studies of disease prevalence. So, twice over, as a label and as a measurement phenomenon, chronic illness seems to have been invented in the 20th century. Finally, Gilleard and Higgs remark that the 20th century interest in disease in later life has ‘not always been beneficial ... though the overall situation is better than before’. The problem is the same as besets causal explanations: what criteria, lying outside the paradigm, can we use for such an evaluation? I noted that pathological explanations replaced the older ones based on ageing (I used the word suppressed, as both could not easily coexist) yet I did not mean to imply that either explanation was better. Something changed, something was different, a new gestalt came over medicine; whether that was a good or bad thing I’m happy to leave to the judgement of others. Address for correspondence: David Armstrong, Department of Primary Care and Public Health Sciences, 42 Weston St, King’s College London, London SE1 3QD. E-mail: [email protected]
References Foucault, M. (1980) Power/Knowledge: Selected Interviews and Other Writings 1972–1977. Ed. C. Gordon. New York: Pantheon Books. Hedley, O.F. (1935) A critical analysis of heart disease mortality, Journal of the American Medical Association, 105, 1405–11. Omran, A.R. (1971) The epidemiologic transition: a theory of the epidemiology of population change, Milbank Memorial Fund Quarterly, 49, 509–38. © 2014 The Author Sociology of Health & Illness © 2014 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd
Revisionist or simply wrong? A rejoinder David Armstrong Department of Primary Care and Public Health Sciences, King’s College London, London, UK
It surely must please any author to know that someone has read their article, but to have a commentary, albeit critical, is a special accolade. So my thanks to Gilleard and Higgs for their time and effort. I think we are agreed that chronic illness is largely a 20th century phenomenon, that it appeared early in the century and grew to become the major morbidity problem it is today. Where we differ is in how this phenomenon is to be explained; and underpinning this disagreement lie our different approaches to what might be construed as an adequate explanation and to method. My article was descriptive in the sense that it tried to take contemporary observations (as recorded in the articles, reports, correspondence and editorials of JAMA) to reconstruct the changing perceptions of the nature of disease and its distribution during the 20th century. My ‘revisionist’ claim was that these changes in perception could account for the apparent growth in the prevalence of chronic illness without invoking a real or biological change in the form or distribution of morbidity. The latter explanations, in fact, emerged only towards the end of the century, well after the cognitive transformation had been accomplished. Why did these changes occur? I prefer to stay agnostic, in part because I am persuaded by Foucault’s (1980) advice to study power ‘where it becomes capillary’ (p. 96), where it has its immediate effects, and in part because I think the contemporary form of causal explanation is itself in need of understanding. For example, the medical shift to multi-causal (multifactorial) explanations of disease aetiology in the second half of the 20th century seems to reflect the same paradigmatic changes that accompanied the emergence of chronic illness. Gilleard and Higgs, however, propose causes as explanations, rather than constructs that themselves need to be explained. They claim, for example, it was the release of beds during World War II that triggered the interest in diseases of later life and it was the desire for higher status that led municipal hospital doctors to form the new specialty of geriatric medicine. We will therefore have to agree to differ on our forms of explanation though, if pressed, I would feel more comfortable in seeing it the other way round: that the new ‘reality’ of chronic illness required new methods of organising health care. Gilleard and Higgs remind us that there is already a body of historical literature for some of the topics I covered – particularly on the place of ageing in medical thought – that identifies debates centuries earlier. I think it is noteworthy that the ‘historical’ literature described in the commentary was all written in the latter half of the 20th century, well after the phenomena I was trying to describe had stabilised and become a part of everyday understanding. I tried to eschew this historical method as it seemed somewhat circular: once chronic illness had been identified in the 20th century it was possible to re-read or reinterpret older texts to identify its existence in the past. Instead I used a (sociological) qualitative method to analyse texts. These were not the transcripts of interviews, as my respondents were mostly long dead, but they had left their own words, as published in JAMA, for me to use in lieu of transcripts. I used Foucault’s analysis of the emergence of modern medicine as a starting point as it enabled me to situate the 19th century discussion of acute and chronic disease in JAMA; but otherwise my article is entirely concerned with what my respondents ‘said’ (or, more accurately, wrote) © 2014 The Author. Sociology of Health & Illness © 2014 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd. Published by John Wiley & Sons Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Maiden, MA 02148, USA
Revisionist or simply wrong? A rejoinder
1117
during the 20th century. None of them mentioned Galenic medicine or the concept of ageing in the early modern period. As in any qualitative analysis I have been selective in reporting from my texts and it is of course my interpretation. Yet if I am wrong in my interpretation then perhaps my respondents should shoulder some of the blame? When, for example, Hedley (1935: 1407) noted that ‘Deaths previously attributed to senility are now listed as heart disease’ was he, too, mistaken? Perhaps Gilleard and Higgs would argue that these commentators failed to see the bigger picture or were unaware of earlier historical debates (though, as pointed out, many of these debates were identified only later in the century). But using my method and my sources all I had to analyse was what my respondents reported and I had no evidence to suggest that they deliberately misrepresented the contemporary world as they saw it. Later in the 20th century, after the construct of chronic illness had materialised, it was possible to devise more elaborate explanatory frameworks involving supposed biological changes, such as Omran’s (1971) epidemiological transition, but my study was largely about that inchoate period before it stabilised. At times contemporary commentators seemed perplexed, at times they grasped for explanations, at times they disagreed. Many reported diagnostic relabelling, a not uncommon practice, as diagnoses often seem to come and go: dementia praecox, for example, an early 20th century diagnosis that once filled inter-war mental hospitals, has now disappeared. But JAMA writers also seemed to be coming to terms with the new idea of population morbidity. The classification of death (by pathological cause) emerged in the 19th century but the first tentative morbidity classifications were a 20th century invention – which can, in retrospect, be applied to earlier centuries. The idea of measuring morbidity in a population (rather than in hospitalised patients) emerged at the exact point that chronic illness or disease emerged from below the threshold of medical perception. It was the measurement of chronic illness in the community that underpinned the inter-war studies of disease prevalence. So, twice over, as a label and as a measurement phenomenon, chronic illness seems to have been invented in the 20th century. Finally, Gilleard and Higgs remark that the 20th century interest in disease in later life has ‘not always been beneficial ... though the overall situation is better than before’. The problem is the same as besets causal explanations: what criteria, lying outside the paradigm, can we use for such an evaluation? I noted that pathological explanations replaced the older ones based on ageing (I used the word suppressed, as both could not easily coexist) yet I did not mean to imply that either explanation was better. Something changed, something was different, a new gestalt came over medicine; whether that was a good or bad thing I’m happy to leave to the judgement of others. Address for correspondence: David Armstrong, Department of Primary Care and Public Health Sciences, 42 Weston St, King’s College London, London SE1 3QD. E-mail: [email protected]
References Foucault, M. (1980) Power/Knowledge: Selected Interviews and Other Writings 1972–1977. Ed. C. Gordon. New York: Pantheon Books. Hedley, O.F. (1935) A critical analysis of heart disease mortality, Journal of the American Medical Association, 105, 1405–11. Omran, A.R. (1971) The epidemiologic transition: a theory of the epidemiology of population change, Milbank Memorial Fund Quarterly, 49, 509–38. © 2014 The Author Sociology of Health & Illness © 2014 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd
