NOTES for "FRAMING DISEASE

1. Portions of this essay are repeated or adapted from the author's "Disease in History: Frames and Framers," Milbank Quarterly 67 (suppl. I, 1989): 1 - 15 and are reprinted with permission.
2. Disease can and must also be seen as a taxonomyÐwith individual ailments arranged in some order-imparting structure. For a more general discussion, see Charles E. Rosenberg, "Disease and Social Order in America: Perceptions and Expectations," Milbank Quarterly 64 (suppl. 1, 1986):34-55.
3. In the sense I have been trying to suggest, an inborn error of metabolism unknown to a generation's clinicians was not, in fact, a disease but rather an analogy in the realm of pathology to the tree falling in the forest with no ear to hear.
4. The emergence of AIDS and the intractability of certain psychiatric conditions made visible by the deinstitutionalization movement have both played an important role in underlining the need to factor in biopathological mechanisms in understanding the particular social negotiations that frame particular diseases. Physicians and social scientists concerned with such issues necessarily inhabit what might be called a postrelativist moment; neither biological reductionism nor an exclusive social constructionism constitute viable intellectual positions. See Charles E. Rosenberg, "Disease and Social Order," passim.
5. There is, of course, an abundant sociological literature in this area, particularly in relation to psychiatric diagnoses. The work of Erving Goffman has been particularly associated with this emphasis. He also used the "frame" metaphor in his well-known Frame Analysis: An Essay on the Organization of Experience (Cambridge: Harvard University Press, 1974) though in a somewhat different context.
6. The very different modes of transmission imply different relationships to relevant ecological and environmental factors.
7. The name of Thomas McKeown has been closely associated with revitalizing this century-old debate; see McKeown and R. G. Record, "Reasons for the Decline in Morality in England and Wales during the Nineteenth Century," Population Studies 16 (1962):94Ð122; McKeown, The Modern Rise of Population (London: Edward Arnold, 1976); McKeown, The Role of Medicine: Dream, Mirage, or Nemesis (London: Nuffield Provincial Hospitals Trust, 1976). McKeown's emphasis on the elusive variables that determine tuberculosis incidence has inevitably drawn controversy, but did focus historical and demographic attention on ecological variables in general and contributed to the intellectually and politically related revival of interest in the history of occupational health. See, for example, David Rosner and Gerald Markowitz, eds., Dying for Work: Worker's Safety and Health in Twentieth Century America (Bloomington: Indiana University Press, 1987); Ann Derickson, Workers' Health, Workers' Democracy: The Western Miners' Struggle, 1891-1925 (Ithaca: Cornell University Press, 1988).
8. Among the most influential works in this area have been A. W. Crosby, Jr., The Columbian Exchange: Biological and Cultural Consequences of 1492 (Westport,CT: Greenwood Press, 1972); Crosby, Ecological Imperialism: The Biological Expansion of Europe, 900-1900 (Cambridge: Cambridge University Press, 1986); William H. McNeill, Plagues and Peoples (Garden City, NY: Anchor Press/ Doubleday, 1976).
9. See, among numerous examples, Karl Figlio, "Chlorosis and Chronic Disease in 19th Century Britain: The Social Constitution of Somatic Illness in a Capitalist Society," Social History 3 ( 1978): 167- 197; P. Wright and A. Treacher, eds., The Problem of Medical Knowledge (Edinburgh: Edinburgh University Press, 1982); Elaine Showalter, The Female Malady} Women, Madness, and English Culture, 1830-1980 (New York: NOTES1.P. 1985). A recent growth of interest in "imperial" medicine reflects an interest in both the ideological and demographic aspects of disease; see, for example, Roy MacLeod and Milton Lewis, eds. , Disease, Medicine, and Empire: Perspectives on Western Medicine and the Experience of European Expansion ( London and New York: Routledge, 1 988); Philip D. Curtin, Death by Migration: Europe's Encounter with the Tropical World in the Nineteenth Century (Cambridge and New York: Cambridge University Press, 1989); David Arnold, ed., Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988).
10. This characteristic helps explain the ambiguous status of psychiatry in medicineÐand the enthusiasm that greeted recent somatic explanations of behavior and behavior pathology.
11. Contemporary patient advocacy groups may represent in part a response to this asymmetrical distribution of knowledgeÐand thus power.
12. With today's sophisticated laboratory medicine and screening of populations at risk, we have created an assortment of pre- or protodisease states accompanied by a difficult assortment of personal and policy decisions. Is the middle-aged male with a high cholesterol level a sufferer from disease? What are his personal responsibilities, and those of society on his behalf?
13. It might be objected that the "actor" metaphor is inappropriate, implying volition and autonomy; strictly, only people can be actors. Perhaps disease might be more accurately considered a "script" specifying future behaviors. I prefer the actor metaphor because of its emphasis on the way disease concepts exert influence as independent factors, constraining the options of human actors in social situations.
14. See, for example, Allan M. Brandt, No Magic Bullet: A Social History of Venereal Disease in the United States since 1880 (New York: Oxford University Press, 1985).
15. The physician's diagnostic situation can reflect another sort of biological reality, the endemic incidence of disease in a particular society. The distribution of sickness constitutes a background against which, and in terms of which, the physician evaluates the comparative plausibility of diagnostic options.
16. Which is not to suggest that the need for decisions in some particular cases precludes conflict in other, parallel instances.
17. Cf. William Coleman, Death Is a Social Disease: Public Health and Political Economy in Early Industrial France (Madison: University of Wisconsin Press, 1982); John M. Eyler, Victorian Social Medicine: The Ideas and Methods of William Farr (Baltimore: The Johns Hopkins University Press, 1979); Erwin H. Ackerknecht, Rudolf Virchow: Doctor, Statesman, Anthropologist (Madison: University of Wisconsin Press, 1965); James C. Riley, The Eighteenth-Century Campaign to Avoid Disease (New York: St. Martin's Press, 1987).
18. Temkin himself was careful to note that he employed the terms "physiological" and "ontological" "for brevity's sake." "The Scientific Approach to Disease: Specific Entity and Individual Sickness," In: A. C. Crombie, ed., Scientific Change: Historical Studies in the Intellectual, Social and Technical Conditions for Scientific Discovery and Technical Invention from Antiquity to the Present (New York: Basic Books, 1963), pp. 629-647. reprinted in Temkin, The Double Face of Janus and Other Essays in the History of Medicine (Baltimore and London: Johns Hopkins University Press, 1977), pp. 441-455. From the present author's point of view, what Temkin refers to as the "scientific approach" should also be seen as the "bureaucratic approach"Ðone that lends itself to the functional requirements of large administrative structures.
19. See, for recent expositions, Arthur Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition (New York: Basic Books, 1988) and Rethinking Psychiatry: From Cultural Category to Personal Experience (New York: Free Press, 1988); Howard M. Spiro, Doctors, Patients, and Placebos (New Haven and London: Yale University Press, 1986); Howard Brody, Stories of Sickness (New Haven and London: Yale University Press, 1987).