Markku Myllykangas & Raimo Tuomainen(edited by Anneli Ekholm)
Oppimateriaali: Health values, media publicity and citizens. Tampereen yliopiston verkkokurssi 2004.
Science - the ruler of our health
Health is a determinant factor of the quality of human life. It is a critical component of well-being. A weakness in health easily leads to problems in any other components of well-being. We support ourselves on science as we improve our living conditions, and science is also the key word in maintaining or enhancing our own physical or mental condition. The aim to cure or to be fit has inspired a great volume of scientists' intensive work, creating truths and disproving truths. Science is nowadays the highest authority and it produces changing facts and verities of progressively shorter duration.
We want to know the right way to live - nowadays religion cannot give adequate answers to a critical public. Because medical science is connected with the problems of "how to live" or "how to avoid suffering", it serves insecure people's hopes. Actually, medicine is only one way of trying to solve health problems, quite a new one: and the weaker the longer we look back historically. The doctors with their medical science achieved their exceptional status only in the last decades of 1800's.
Modern medicine can be seen to originate at the end of the 1700ts. At the beginning of the 1800's clinical doctors were able to describe something which had been unseen or outside the observation. Autopsy had generated a basis for the development of an anatomical-clinical system - as autopsies became a practice, clinical observations could be correlated with findings in tissues - and the concept of illness was fixed with the human body. Medicine evolved, along with the general Western social development, into a clinical science: instead of a patient doctors saw a sickbed of a clinic - a field of scientific research. (Foucault 1975)
During the 20th century there occurred a significant mental change: biomedicine became a central part of medical science. First there was "medicine as an art", then "medicine as a science" (Lyng 1990). Gordon (1988) has stated that clinical appraisal has traditionally been classed under the term of 'art', but modern medicine flows somewhere between 'art' and 'science'
Penicillin can be counted as one of the ten most important inventions of mankind. According to Sontag (1982) it was finally the success of antibiotics in conquering many malignant diseases that made people accept the wisdom of medicine: many diseases originated from micro-organisms and medicine was sovereign in curing them. Foucault (1975) took the view that as our medicine has developed, the conception of disease has also been distinguished from metaphysical bad - and human illness has come under the rules of positivistic science. The supernatural context in explaining human illness has vanished; if not totally then, at least out of sight, is.
Now, the maturing of surgery to the age of transplant technologies has built up the glamour of medicine and raised the human dream of a self-regenerating organism to a concrete aim of science. (Tuomainen etc. 1995).
Zola (1972) is the father of concept 'medicalization'. It means an expansion of the medical institution and reviewing deviance and the processes of human life from a medical perspective. In the process of medicalization the power of medicine extends to areas which were considered non-medical. For instance overweight, certain use of stimulants or certain sexual behaviour or difficulties in falling asleep have become diagnoses.
The concept 'medicalization' has been determined in various ways. The central idea has been to talk about it considering the status of medicine and the power of medical doctors: doctors control us more and more. But, in a narrow sense, it means that human decisions (both on a personal and a common level) increasingly rest on facts that medicine has generated. People have begun to state the terms of medical science and judge things more and more on the basis of medical statements.
The process of medicalization also means that we listen carefully what the agents of medical science tell us to do; and doctors seem to have message about a widening range of human life. Medicine corners new areas both on a greater and lesser scale.
It was indisputably McKeown (1976) who laid the foundation for the rational critique of medicine by identifying its social overvaluation. His thesis was that in fact medicine has had a quite marginal effect on public health. The changes in environment explain the disappearance of a major part of the various infections and the fall in mortality. Illich and Zola (e.g. Illich etc. 1977) have progressed far in radical medical critique, together and with their own personal publications. Their books have reached a status of unquestioned classics of medicalization theories. Conrad and Schneider (1980a, 1980b) have a more neutral reputation among social scientists, but the valuation of their works connects many kinds of medicalization theorists. In Finland the public medicalization debate really began as late as during the 2000's, but before that some researchers of the University of Kuopio especially attracted attention with their articles, also causing indignation. (Tuomainen etc. 1999)
The doctor has a legitimate right to examine and cure our bodies and minds. Any matter related to body or mind can be treated as a medical problem. This tendency to detect medical problems everywhere does not necessarily spring from a zealous medical institution but is linked to a broader social context and the common need to explain and control the course of life. One can speak about "disease mongering": turning ordinary ailments into medical problems, seeing mild symptoms as serious, treating personal problems as medical ones, and seeing risks as diseases. Medical scientists find new diseases and syndromes and try to categorize abnormalities and peculiarities. For instance, some social and mental problems have already long been labelled medical.
The clearer the deviance can be seen as a biomedical phenomenon, the stronger is its medical stigma. Explanations which are bound to soma are more emphatic than definitions resting on observable behaviour. There are attempts to connect mental deviance to physical response. In the classic trialism 'biological - mental - social' particularly the biological realities have been perceived as most decidedly the substance of medicine. Now, the critics of biomedicine especially have claimed that it is unnatural to view a man as a biological entity, out of his mental, social or natural settings. If we take the holistic health theories seriously enough, we just cannot find any specific section for medicine; it is like Tao, in everything. And if we go further with this line of thought, medicine can legitimately interfere in every aspect of life.
Ever stronger medicine
In the West we have no difficulties in detecting the process of medicalization. Its concrete expression is the expansion of industries and financial flows connected to health (Conrad and Schneider 1980a). And more abstractly, it can be seen as a sharpening awareness of health risks and as a broadening concept of health. In politics and administration medicalization also emerges: health wisdom and health hazards have a great effect on the results of the policy-making; in practice the status of medicine and health care is determined.
In the Western world health care has become one of the main institutions. The number of doctors, nurses and other health care staff has increased everywhere during the last decades. The growing significance of medicine can also be noticed when we view the capital flow of scientific research: medical projects absorb a large part of them. In many countries the pharmaceuticals industry has evolved into a vital and profitable business, in the wake of the growth of medicine.
Health care has long been a significant business activity. It gives jobs, money and power to many well-educated, to nonaltruistic people, too. Chronic competition is a characteristic of health care: in addition to material benefits many people are interested in having authority or gaining status in the academic community. This all has an impact on the actions, orientation, routines and image of health care. (Myllykangas 2001)
Conrad and Schneider (1980a) point out of the exceptionally secure position that medicine has: it can largely create its own demand. Trying to convince essentially well people that they are sick, or slightly sick people that they are very ill is big business. Illich (1976) has claimed that in health care there are perpetually more jobs due to actions of doctors. The treatment often has sideeffects or causes insecurity or suspense, which must be cured. And sometimes, of course, real malpractice occurs.
As women perceive their symptoms and use health services more actively than men, it can be said that medicalization has broken out above all among the fair sex. Women make up the majority of both health care staff and patients, but the leaders are generally male. Many feminists have argued that medicine is not primarily a science but a sexist ideology bolstered by male doctors. The tradition of women's studies has specifically proclaimed the threats of medicalization and warned that reproduction and psycho-social problems should be spared the manipulation of medicine. (Rauhala 1985).
More and more drugs are used for many other aims than the primary treatment of a disease. They are seen as a remedy when we want to constrain our heartbroken mind, to slow loss of hair, to slim down or to harden erection. These are just a few concrete examples of the triumph of medicalization. (Klaukka 1999)
The new medical science is substantially profiled by the visions the medical top disciplines share, especially representatives of molecular genetics. According to them we shall soon witness a revolution of medicine and health care: widespread illnesses as well as severe and uncommon diseases can be cured and eliminated with methods we have not seen ever before. Such excessive optimism has recurred frequently in the history of modem medicine. (Helén 2002)
The health industry pumps out new cures at an accelerating pace. These are not even thought to be used as a treatment of a disease but as a cosmetic aim or to serve narcissistic, foppish interests. Once upon a time there were sick people, who undoubtedly needed new methods of treatment - now we have sophisticated methods, for which we should find users. (Myllykangas 2001)
Healthy life of the citizen
One essential goal and achievement in medicine is the liberation of human beings as a race, as a community and as individuals from the vicious circles of biological necessities. A very essential part of the medical power is the promise to put the limits of life as far as possible and thus allow all to live, if not yet an eternal but a better life. To fulfill this promise people have to accept the actions of medical authorities and they have to change their behaviour, too, and yield to medical subjects. (Helén 2002)
The continuing monitoring of health hazards is a very good example of the relationship between the experts and lay people of the modem world. Medical experts constantly create new knowledge on different kinds of risks, and try to disseminate this knowledge to lay people. And the new awareness has an impact: lay people change their behaviour and way of life because of those new findings — the impact is usually greater among highly educated people. The scientific truths and behavioral guidelines last only some time and are soon replaced by new ones. Some time ago smoking was advisable for recreation. Secondly, we have to remember that in medicine there are always opposing opinions about health risks. (Giddens 1991)
A model citizen takes the most recent health advice seriously and avoids known risks. As nowadays the scientific truths are abolished and risks are changed sooner and sooner, life is full of refreshing alternation. It can be anxious that the general advice is not necessarily suitable for the individual, but fortunately many people do not doubt anything - and if they understand, they can repress it.
Because of the expansion of medicalization, diagnostic tests and visits to physicians are increasing. Thus false positive results will also inevitably increase because the tests are carried out with low predictive value. People are groundlessly diagnosed with disease, further unnecessary tests are needed and unnecessary treatments are initiated. Thus the prevalence of diseases is increasing, at least as a subjective feeling and stigmatization, even if people's health status remains the same. The cost-effectiveness of health services is plummeting.
There are very good conditions in our society for the expansion of medicalization. Tuomainen et al. (1999) have claimed that medicalization gets its power by answering to six needs, the first three work on the individual level and the next three help to keep the social order:
1. the need for a truth authority
2. the need to get rid of guilt and to externalize problems
3. the need to indulge narcissism
4. the need to restrict deviance
5. the need to support market
6. the need to maintain power structure.
Industrial societies have built well-functioning security systems for their citizens. Health care systems and organizations practising health promotion are a part of those systems. But we can ask if the awareness of health and health ideology have in a way undermined security by making people worried about maintaining their health status and by presenting new, endless threats and everyday risks.
Medicalization has opposite effects. On the one hand it creates guilt (the awareness of risks) and on the other hand it exonerates from guilt (it is not my fault, it is that disease).
In a medicalized culture people have learned to cure their symptoms. Tiredness is one of the basic symptoms of the modern, working human being. It has been made into a disease, although usually the human psyche and the body are not sick when they resist their destiny. The situation in which the people have to live may be sick. Especially if people at least sometimes do not have liberating experiences to fulfill themselves and be part of a net of human relationships, where one can be weak, too, sickness is health: life has to be changed. (Tuomainen 2002)
If social values are hard, medicalization can lead to even harsher control: deviance can easily be stigmatized as a disease which needs to be treated. New cultural phenomenon could be destroyed in this way. And: can the meaning of life be readjustment to the tough competition and avoiding risks? If the responsibility of the people is to stay healthy and if the quality of babies is strictly controlled, we shall be approaching the ideals of a certain German dictator. (Tuomainen 2001)
The most important mission of medicine is to help people who are suffering. It has been a way to make society more equal: sick people have come closer to normal people. If the wildest scenarios of genetics come true, medicine is going to create a more obviously unequal society. People can be improved even before birth — we can choose those who deserve the miracle of birth. The children of the rich will get their blessing and be born consonant with their rank. Is the lowest class then those who have to live without genetic conditioning or those who because of that caring are saved gently and austerely from life?
Medicalization can give promises to people that many diseases will be cured, but not only good news. It brings high costs, feeling of guilt, dissatisfaction with oneself, irresolution to deal with symptoms, that were once nothing but normal.
It creates a new kind of polarization, divides people into two groups — people who behave right or wrong.
Medicalization is expanding because of the development of medicine and technology. New treatments to cure disease which were formerly incurable are developed continuously - also for illnesses, which formerly were trivial. New techniques are fast insisted on as routines, for all the people without any question. (Niiniluoto 2003)
The uncontrolled expansion of medicalization should be prevented using different methods (Mustajoki 2003):
- medicalization has to be discussed during medical studies
- physicians have to lean on mainly independent research reports, not the information produced by sponsors
- patients' own health actions have to be supported by practising physicians - it must be discussed, how far it is reasonable to go in treating risks and in doing screenings
- in medical informing the illusion of the omnipotence of medicine must be dispelled
- a national medical council should be established to critically assess medical events and give guidelines concerning "dubious" diagnoses, screenings etc.
We can justifiably take a sceptical attitude towards the theorizing of medicalization. We may think that it overemphasizes one social institution, one profession, one value orientation of people and one social policy orientation. Social trends are vague, and especially concerning single trends the outlining of general development is disturbed by many opposite trends. However, seeing the development of Western cultures and Finland, too, the twentieth century can be remembered as the century of medicalization. That period made the health care system a mighty exerciser of power, raised the health awareness of people and made the state to minister to the health of its citizens. Medicine and medical truths live persistently in our minds. We feel sick more consciously.
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