MEDICINE IS in the throes of a significant conceptual upheaval. The holistic health movement that is so active and so visible in America is one front of a real revolution fueled by public dissatisfaction with the excesses and deficiencies of modern scientific treatments. Everywhere patients are beginning to realize that technological medicine has become too expensive, too dangerous and not effective enough at treating the major killing diseases like cancer and cardiovascular disorders.
Conventional medicine views human beings as isolated physical mechanisms that get sick when they come into contact with disease-causing substances like germs and toxins. The new philosophers of holistic medicine see human beings as composites of body, mind and spirit who get sick when normal balances among internal and external forces break down. The difference in viewpoint centers on what are the true causes of illness. The materialism of regular medicine leads it to confuse the agents of disease with the causes of disease. It is not that we get hepatitis when we meet up with a hepatitis virus, but that we get hepatitis because we meet up with the virus when we are in susceptible state. If we are in the balanced state called health, we can meet and interact with potential agents of illness and injury without suffering ill effects. The real causes of illness are the determinants of susceptibility to these agents.
What makes us susceptible to illness? Clearly, many factors operate. Some are physical, like malnutrition or fatigue. Some are mental, like depression, fear, repressed anger, or an unconscious desire for a break from the workaday routine. The present book examines social causes of illness, which tend to be neglected by holistic doctors in their excitement at rediscovering the mind and spirit. According to author Richard Totman, "People, in their dealings with others, follow social rules. When they stop following rules, for whatever reason, they are likely to become ill." Totman goes on to define "rules" as one's characteristic and consistent "ways of relating to the social environment." Social involvement protects us against susceptibility to disease, he says, and it can take two forms: "(1) conversation with other people, in which a degree of personal commitment is expressed, and (2) preoccupation in activity, whether carried on alone or in company, which is directed toward a definite goal or end-product, and which entails a modicum of effort."
Despite Totman's reasonable thesis and his clear writing, Social Causes of Illness comes across as unexciting, partly because of the book's structure. The author leads us to expect an earthshaking new theory of illness. He criticizes other models and introduces his own as the one that will unify all the data. After this build-up, Totman's conclusion that social involvement protects us against susceptibility to disease is anticlimatic.
In fact, the earlier chapters of the book make much better reading than the later ones. The second chapter, entitled "Dissonant Cures," reviews some of the more horrible methods used to treat illness in the past -- ointments prepared from boars' brains and fat, imetics made from nail parings, powdered human heart given as a cure for epilepsy -- and analyzes their effectiveness in the light of the "cognitive dissonance" theory of modern psychology. A sick person who submits to an unpleasant treatment must justify to himself the unpleasantness he has sustained. The tension, or dissonance, created by this need may activate internal healing mechanisms of the body and bring about a cure, even though the treatment itself has had no direct effect on the condition.
But Totman has little interest in these mechanisms and is unable to see how psychosomatic interactions can be studied profitably. He writes: "It is beyond our reach as scientists to envisage how a pathological organic condition could be the result of anything other than a chain of organic causes and effects. To say that it resulted from feelings of 'guilt' or 'despair' simply leaves us in mid air." After he has dismissed psychosomatic theories of illness as impossible to research, he proposes his own "structural theory" of social causes that, while it is probably correct, seems neither very interesting nor very helpful.
The fact is that the most exciting frontier of medical research will be mind-body interactions. I have no doubt that we will soon begin to understand just how guilt, despair, fear and, especially, belief translate into real physical processes mediated by nerves and neurohormones. For example, the recent discovery of endorphins, the opiate-like substances produced by our brains, may provide a mechanism for certain kinds of placebo effects. Already we know that the anesthetic effects created by acupuncture needles can be partially blocked by narcotic-antagonist drugs, suggesting that the endorphin system, rather than cognitive dissonance, explains acupuncture's effectiveness as a pain-killer.
We have yet to find out, or even begin to study, why warts fall off within hours after they have been treated by a variety of bizarre methods having nothing in common with each other except patients' belief in them. How is belief translated into action at the tissue level? We do not know, but the question can certainly be studied once it is formulated correctly. The answer will have great practical relevance to the management of cancer and other illnesses that modern scientific medicine cannot treat except by the crudest means. (Surgery, radiation and chemotherapy are crude in that they destroy normal tissue almost as effeciently as cancer tissue.)
It is desirable to explore the social causes of illness, especially since they are so often ignored, and Richard Totman's book provides some food for thought on this subject. Against the larger background of new ideas now stirring throughout the whole field of medicine, however, it seems conservative and beside the point.