On The Concept of Disease Publ

On the concept of disease 1
Fernando Dias de Avila-Pires
On the concept of disease*
Author: Fernando Dias de Avila-Pires**

Kind of paper: Article.
* Acknowledgments: Marcia Grisotti and Márcia Pfuetzenreiter read, discussed, and

commented on this text. With Adriana Mohr and François Delaporte I kept lively discussions
concerning some philosophical and practical issues related to realism and social
constructivism. Stephen M. Sacks encouraged the writing of an earlier version of this article
and offered valuable comments.
** Department of Tropical Medicine. Institute Oswaldo Cruz , Rio de Janeiro, Brazil.
favila@matrix.com.br
ABSTRACT
The concept of disease is here revised according to the Systems Theory of Levels of
Complexity. The objective reality of pathological lesions and organic and mental dysfunctions
is admitted as characteristic of the individual level of organization. Diseases, though, are
defined as social constructs of collective nature. Current definitions of disease fail to
recognize the fact that diseased and diseases belongs to distinct levels of complexity. The
question of anachronism in diagnosing pathological conditions in the past is addressed.
Key words: diseases; levels of complexity; systems theory; anachronism; social constructs.
RESUMO
O conceito de doença é discutido segundo a Teoria dos Níveis de Complexidade. A

realidade objetiva das lesões patológicas e das disfunções orgânicas e mentais é admitida
como característica do nível individual de organização. Doenças, entretanto, são definidas
como construtos sociais de natureza coletiva. As definições correntes de não falham em
reconhecer o fato de que doentes e doenças pertencem a níveis de complexidade distintos.
A questão do anacronismo no diagnóstico de condições patológicas no passado é
analisada.
Palavras chave: doença; níveis de complexidade; teoria de sistemas; anacronismo;

construções sociais.
1
Revista de Historia & Humanidades Médicas
Vol. 4, Nº 1, Julio 2008
www.fmv-uba.org.ar/histomedicina
RESUMEN
El concepto de enfermedad es revisado aquí de acuerdo con la Teoría de los Sistemas de
los Niveles de Complejidad. La realidad objetiva de las lesiones patológicas y las
difunciones orgánicas y mentales es admitida como característica del nivel individual de
organización. Las enfermedades, sin embargo, son definidas como construcciones sociales
de naturaleza colectiva. Las definiciones actuales de enfermedad fallan al no reconocer el
hecho de que enfermos y enfermedades pertences a distintos niveles de complejidad. Se
retoma la cuestión acerca del anacronismo en el diagnóstico de condiciones patológicas en
el pasado.
Palabras clave: enfermedades; niveles de complejidad, teoría de los sistemas,

anacronismo; construcciones sociales.
2
On the concept of disease
Disease is a biological process older than man.

1
George Rosen
INTRODUCTION
Defining disease and health is both a necessity and a challenge. It has been
attempted by anthropologists, sociologists, philosophers, biologists, and medical doctors.
The very need for a definition has been questioned recently1, but a clear theoretical concept
and an operational definition are certainly needed. Seedhouse 2 and Nordenfelt 3 4
justified
that need not only as a matter of purely philosophical speculation and applied philosophical
research, but also for pragmatic reasons, as a reference for legal litigations and health care
policies. It is also a requisite to allow doctors and patients to understand each other.
A growing body of literature addresses this question, but a thorough bibliographic
review will show that the failure to distinguish between phenomena pertaining to distinct
levels of complexity has so far confused the actual issue and led frequently to fruitless
arguments.
Inventions and discoveries like the world of microbes in the 17th Century, the cell in
the 19th Century, and the molecular basis of biological phenomena in the 20th Century,
certainly improved our knowledge of health and disease. But phenomena taking place at
lower levels of complexity - those of the molecules and the cells - had little influence upon
our philosophical conceptualization of health and disease at the individual or higher levels.
Recently, Temple et al 5 proposed a new definition of disease. Their approach did
little to improve on previous attempts. For them, disease is a state that places individuals at
increased risk of adverse consequences. If we adopt their definition, we would be forced to
recognize that getting old qualifies and also, for that matter, driving a car, getting married,
breathing, eating, or simply, being born: all those states carry a "risk of adverse
consequences". They failed to recognize that disease is not an attribute of a patient, but a
generalization from a large number of particular, individual observations. Sasz 6 remarked on
1
Rosen, George, From medical police to social medicine. Essay on the history of medical care,
NewYork, Harper & Row, 1980
2
Seedhouse, David, “Clarifying the task”, Theorethical .Medicine, volumen 14, Netherlands,
1993, pp. 287-294
3
Nordenfelt, Lennart, “On the relevance and importance of the notion of disease”, Theorethical
.Medicine,volumen 14, Netherlands, 1993A, pp.15-26.
4
Nordenfelt, Lennart, “Concepts of health and their consequences for health care”.
Theorethical Medicine,volumen 14, Netherlands, 1993b, pp. 277-285
5
Temple, Larissa K.; Robin McLeod; Steven Gallinger; and James Wright,. “Defining
disease in the genomics era”. Science, volumen 293, número 5531, New York, 2001, pp. 807-
808.
6
Szasz, Thomas, Sins of the fathers, http://reason.com/0208/te.ts.sins.shtm., 2002
3
the narrow, sometimes indistinct limits that separates morality, sin, and crime, reaffirmed his
polemic opinion of 1961 7 of the inexistence of mental diseases. He also showed how
tradition and respect for religious beliefs and norms affect social views and legal
dispositions. Saz 8 reduced disease to one of its components, when he sustains that disease
is a biological process that occur in our bodies, a vision reminiscent of the old conception of
Littré and Robin 9 .
FOR A NEW CONCEPT OF DISEASE
A simple and direct answer is not sufficient to take into consideration all the complex
aspects involved in the conceptualization of disease.
A historical approach may be of help. The historian of medicine may follow several
avenues of inquiry. He may produce a historiography of discoveries. A paradigmatic example
is the revision of the currently accepted views concerning the discovery of Chagas disease,
published by Delaporte 10 . He may analyze the changing concepts and diagnostic procedures
concerning a certain disease in medical literature, from the past to present times. An
example is the recent change in the etiologic explanation of gastric ulcers, from a presumed
inflammatory condition of psychosomatic nature to be treated with anti-acids and dieting, to
a bacterial infection responsive to antibiotics. Wilson 11 explored this venue showing it to be a
domain of historical investigation of its own right, distinct from - though by no means
independent of - such more familiar history-of-medicine themes as the history of anatomy
[...]. Or else, he may be interested in the identification of diseases in early descriptions,
travelogues, reports and chronicles of explorers. Yet another venue is to make retrospective
diagnoses in an attempt to fit early descriptions of ailments or anomalies found in fossil,
prehistoric or historical remains into current categories of diseases 12 . This type of reseach
falls into the special fields of paleopathology and paleoparasitology. An example is the
search for the influenza virus of 1918 in corpses frozen in ice or preserved in collections of
pathological specimens. Some authors criticize such attempts as anachronistic while others
find merit in these regressive efforts 13 . A bitter argument surrounded the identification of
7
Szasz, Thomas, The myth of mental illness, New York, Harper and Row, 1961
8
Szasz, Thomas, Sins of...
9
Littré, Emil et Charles Robin,. Dictionnaire de médecine, volumen 1, Paris, J. Baillière, 1858
10
Delaporte, François, La maladie de Chagas, Paris, Payot, 1999
11
Wilson, Adrian, “On the history of disease concepts: the case of pleurisy”, History of
Science, volumen 38, Falmer, Sussex, 2000, pp. 271-319
12
Waldron, Tony, Counting the dead: the epidemiology of skeletal populations. London, Wiley,
1994
13
Jardine, Nick, “Uses and abuses of anachronism in the history of the sciences”, Hisory of
Science, vol. 38, Falmer, Sussex, 2000, pp. 251-270.
4
14
tuberculosis as the cause of death of Ramsés II This argument was taken over by hard-
line relativists and post-modern social constructivists who denied the existence of the reality
of scientific facts, as merely mental constructs, and as valid as any other alternative
explanation. Zoologists and botanists, though routinely include a chapter in their taxonomic
papers in which they disentangle nomenclatorial problems not unlike those encountered by
historians of diseases without any qualms concerning anachronism. To identify an animal
specimen collected in the early 1800's found preserved in a museum case as a species
recently described, is a recognized routine practice. No one would dispute it as anachronistic
on the grounds that when the specimen was preserved its name and scientific description
had not yet been published. Wilson 15 recognizes that retrospective diagnosis suppresses
precisely what the history of disease-concepts brings to the fore, namely the content of the
past descriptive and diagnostic categories. Finally, the historian may follow the changes in
morbidity/mortality rates caused by a disease, due to the improvement of living conditions
and the adoption of more efficient preventive measures, the availability of new diagnostic
methods for early detection, or the advent of new drugs and therapeutic procedures altering
the estimates of life expectancy in populations. Or else, he may try to follow the changes in
virulence or emergence of diseases in the course of time due to the biological evolution and
dispersal of its agent, which is a task to be approached with the help of a sound knowledge
of biology and epidemiology. An example is the loss of virulence shown by the syphilis
agent in modern times, as compared with its ravages in Europe during the Renaissance.
THE ANTIQUITY AND THE OBJECTIVE REALITY OF PATHOLOGICAL CONDITIONS
Three and a half billions of years ago life emerged on Earth. Paleontologists are
presently able to reconstruct phylogenetic sequences of evolving organisms or taxa. Along
their evolution, organisms have established or lost permanent relationships and
partnerships, have exchanged genes, RNA and DNA.
Pathological conditions, signifying alterations in the body structure, or in genetic,
developmental and physiological processes, are inherent to life. We may well conceive its
early manifestations in the unsuccessful replications of the earliest polymeric self-replicating
chains, and follow its evolution through time 16 . They occur at the individual level.
Paleopathologists are able to recognize pathologies in fossils that lived millions of
years ago. Certain environmental conditions favour the processes of fossilization and
mummification. Many animal and plant fossils exhibit alterations which are the result of
14
Latour, Bruno “Ramsés II est-il mort de la tuberculose ?” La Recherche, volumen 307, Paris,
mars 1998, pp. 84-85.
15
Wilson, Adrian, “On the history of disease ...
16
Margulis, Lynn and Dorion Sagan,. Microcosmos. Four billion years of microbial evolution,
Berkeley University of California Press, 1986.
5
accidents, trauma, and fractures. Degenerative diseases like osteoporosis, teeth decay,
malnutrition, congenital malformations, leave traces on bones and tissues. Congenital
lesions like hydrocephaly and cleft palate, metastatic tumors, microbial or parasitic
infections, and necrotic processes, can often be recognized. For a long time
paleopathologists have described and diagnosed abnormalities in fossils, both non-human
and human, in a way similar to a neontologist's description of abnormalities in wild animals
preserved in museum collections. Paleoparasitologists, working in partnership with
archeologists and historians are now able to submit coprolites to routine laboratory analysis
in order to determine the centers of origin and routes of dispersal of human and animal
parasites. Bones and teeth survive well the wear and tear of time and their diseases have
received frequent attention from zoologists, paleontologists and pathologists. Fossil plants
also show signals of diseases that phytopathologists are able to diagnose 17 18 19 20 21 22 23 24
25
.
Artificial preservation or mummification of corpses, organs, parts, and remains of
humans and domestic animals has been ritualistically practiced in many cultures. Nowadays,
detailed studies of mummies using modern resources of internal imagery and laboratory
analysis are helping to draw a picture of common ailments in early historical and prehistoric
times, advancing considerably our knowledge of paleopathology. 26 27 28 29
To deny the reality of pathological lesions and to relegate them to ephemeral social
constructs is to deny the very existence and nature of fossils. If we admit that organisms
lived in the past, before the arrival of the human species on the scene, we forcibly have to
accept that they lived in health and in illness, as they do nowadays. Accidents, injuries,
17
Bennejeant, Charles, Anomalies et variations dentaires chez les primates, Clairmont-
Ferrand,Vallier, 1936.
18
Bennejeant, Charles, “Les anomalies dentaires numériques des primates”, Bulletins et
Mémoires de la Societé d’Anthropologie, volumen 5, número 10, Paris, 1954, pp. 154-197.
19
Foucault, Michel, Histoire de la folie à l'âge classique, Paris, Gallimard, 1972.
20
Gyldenstolpe, Nils, Zoological results of the Swedish expedition to Central Africa, 1921.
Mammals from the Birunga volcanoes, north of Lake Kivu, Archiv forZoologi, volumen, 20A ,
número 4, Stokholm, 1928, pp. 1-76.
21
. Howell, A. Brazier., “Asymmetry in the skulls of mammals”, Procedings of the United States
National Museum,volumen 67, número 27, Washington, D. C., 1925, pp. 1-18.
22
Lewin, Roger, Patterns in evolution, New York, Scientific Amererican Library, 1997.
23
Smith, James D.; Hugh Genoways, and John Knox-Jones, Jr., “Cranial and dental
anomalies in three species of Platyrrhine monkeys from Nicaragua”, Folia primatologica,
volumen 28, Zurich, 1977, pp.1-42.
24
Toldt, Karl von,. “Asymetrische Ausbildung der Schläfenmuskeln bei einen Fuchs infolge
einseitiger Kautätigkeit”, Zoologischer Anzeiger,volumen 39, Berlin, 1905, pp. 176-191.
25
Vaughan, Terry A., “Cranial asymmetry in the pocket gopher”, Journal of Mammalogy,
volumen 42, número 3, Baltimore, 1961, pp.412-413.
26
Harris, James and Paul V. Pontz, Dental health in ancient Egypt. In: Cockburn, A. and E.
Cockburn, Mummies, disease and ancient culture, Cambridge, Cambridge University Press,
1980, pp. 45-51.
27
Moodie, Roy L., Paleopathology. An introduction to the study of ancient evidences of
disease, Illinois, University of Illinois Press, 1923..
28
Pales, Leon, Paleopathologie et pathologie comparative, Paris, Masson, 1930.
6
physiological dysfunctions, are facts of everyday life. Parasites and microorganisms now
living are descendants of ancestral of old. Genetic, anatomic and functional anomalies are
neither novelties nor human intellectual creations. They have existed for billions of years.
Man is a late arrival on this scene. So, while explanations and social constructs are cultural
or meme novelties, pathologies are not. They are as old as life itself, of which they are part.
Confusion arises when we fail to distinguish the reality of lesions and dysfunctions with the
social construction of diseases.
As to mental diseases, it is arguable if they have a “natural history”. As social
maladjustments or comportamental diseases, they are actually social constructs.
COMPLEXITY THEORY AND A NEW CONCEPT OF HEALTH AND DISEASE.
In 1993 a whole issue of the periodical Theoretical Medicine was dedicated to the
30 31 32 33
concept of health, a favorite subject of social scientists and medical doctors alike
34
In this paper we argue that, for a proper understanding of this issue we must turn to the
systems theory of the levels of complexity 35 36 37 38 39 40 41 42 43 44 45
29
Wells, Calvin, Ossos, corpos e doenças, Lisboa,Verbo. 1969.
30
Herzlich, Claudine, Santé et maladie: analyse d'une réprésentation sociale. Paris, École des
Hautes Études em Sciences Sociales, 1992.
31
Hesslow, Germund, “Do we need a concept of disease ?” Theorethical Medicine, volumen
14, Netherlands, 1993, pp.1-14.
32
Latour, Bruno “Ramsés II est-il mort de la tuberculose ?” La Recherche, volumen 307, Paris,
mars 1998, pp. 84-85.
33
Nordenfelt, Lennart, “On the relevance and importance of the notion of disease”,
Theorethical .Medicine,volumen 14, Netherlands, 1993A, pp.15-26.
34
Unschuld, Paul, “Plausibility or truth ? An essay on medicine and world view”, Science in
Context,volumen 8, número 1, Tel Aviv, 1995, pp. 30.
35
Avila-Pires, Fernando .D., Medical ecology, holism, and circular reasoning in medicine. In C.
Susanne and L.Gallé, eds., Ecotechnie and sustainable development. Szeged, Officina
Nyomda, 1998.
36
Bergandi, Donato, Fundamentals of ecology de E.P.Odum: véritable "approche holiste" ou
reductionnisme masqué ?. Buletin d’Écologie, volumen 24, número 1, Paris, 1992, pp. 57-68.
37
Bergandi, Donato, “Reductionist holism”: an oxymoron or a philosophical chimera of
E.P.Odum’s systems ecology ?. Ludus Vitalis, volumen 3, número 5, Paris, 1995, pp. 145-179.
38
Bernard, Claude, Introduction à l’etude de la médecine expérimentale, Paris, Baillière, 1865.
39
Bertalanffy, Ludwig. von, General System Theory, New York, G.Braziller, 1988.
40
Beveridge, William, Seeds of discovery, London, Heinemann Educational Books, 1980
41
Durkheim, Emile, Les règles de la méthode sociologique, Paris, 1895.
42
Looijen, R.C., Holism and reductionism in biology and ecology, Dordrecht, Kluwer, 2000.
43
Le Moigne, Jean-Louis, Complexité, In Lecourt, D., ed., Dictionnaire d’histoire et
philosophie des sciences, Paris, PUF, Presses Universitaires de France, 2003, pp. 205-215.
44
Prosser Ladd, Levels of biological organization and their physiological significance, In
Moore, John, ed., Ideas in modern biology: Proceedings XVI International Congress of
Zoology,volumen 6, , Garden City, Natural History Press, 1965, pp. 357-390.
45
Vemulapalli, Krishna and Henry Byerly, “Remnants of reductionism” Foundations of
Chemistry, volumen 1, número 1, Netherlands, 1999, pp.17-41.
7
According to this theory, distinct phenomena emerge at different levels of

complexity: atomic, molecular, cellular, individual, population (or social), ecosystem, and
cosmic. Heisenberg’s principle of indeterminacy, for instance, is valid only at the atomic
level. Cells are the unity of life, and at the cellular level, life emerge. At the population level,
the uncertainties of individual events become statistical probabilities that can be calculated
with a certain degree of precision. The realm of epidemiology belongs in the level of the
ecosystem.
The idea that phenomena taking place at lower levels of complexity cannot permit us
to foresee what happens at higher levels, is not new. One classical instance is Lavoisier's
realization that we cannot deduct the properties of water from the separate properties of
46
oxygen and hydrogen. Émile Durkheim established the basis of sociology upon the idea
that social phenomena are essentially distinct from the realities and behaviour of individuals.
For him, we must search the explanation of a social fact in another social fact, never on
47
individual behaviour. The novelist James Lasor illustrated the social phenomena through
the words of the English medical doctor Thomas Browne, of 1682, for whom If there be any
among those common objects of hatred I do condemn and laugh at, it is that great enemy of
reason, virtue, and religion, the multitude; that numerous piece of monstrosity, which, taken
asunder, seem men, and the reasonable creatures of God, but, confused together, make but
48
one great beast, and a monstrosity more prodigious than Hydra. Bronowski applied it to
the theory of language stratification. Conversely, the theory of causal determinism is at the
source of reductionist thinking, established by René Descartes. Laplace defended the notion
that if there was a superhuman intelligence capable of knowing the position and momentum
of every atom in the universe and solving all mathematical equations, it would know, with
precision, in the minutest detail, of event in the future or in the past. It was also an outcome
49
of the Newtonian deterministic view of physics . Reductionism was fashionable at the end
th
of the 19 Century when it was believed that all phenomena could be reduced to physical
laws. The discovery of the laws of behaviour of gaseous substances challenged the
deterministic view of universal phenomena. Although the swirling, random, movement of
individual particles is totally unpredictable, gases as a whole conform to the mathematical
laws of pressure and temperature. The calculus of probability, Poincaré’s law of large
50
numbers and chaos theory, all relate to the theory of complexity. Ayala and Dobzhansky
51
and Simpson 52 , among many others, addressed the question of reductionism in biology.
46
Durkheim, Emile, Les règles...
47
Lasor, James, Passport to oblivion. London, Pan, p. 34, 1965
48
Bronowski, Jacob, The origins of knowledge and imagination, New Haven, Yale University
Press, 1979.
49
Beck, William S., Modern science and the nature of life, London, Macmillan, 1958
50
Poincaré, Henry, Science and method New York, Dover,.s/d.
51
Ayala, Francisco and Theodosius Dobzhansky, eds., Studies in the philosophy of biology:
reduction and related problems, London, Macmillan, 1974.
52
Simpson, George G., This view of life, New York, Harcourt, Brace & World, 1964.
8
Reductionism was fashionable in the end of the 19th Century when it was believed that all
phenomena could be explained according to the laws of physics. It returned recently with the
rise of “molecular” biology, and a false attempt at reducing the complexity of biological
53
phenomena to genes or DNA. Bergandi showed the difficulties in finding appropriate
methods to approach complex phenomena at their level of complexity. He showed how
Odum established a theory of ecosystems based on the idea of levels of complexity but fell
in a trap when he suggested a reductionist methodology for ecosystems analysis. Bertalanffy
54
and others established the General Systems theory upon that same idea.
For our purpose, we will not concern ourselves with phenomena that takes place at
the molecular or cellular levels. It suffices to recognize the contribution of Mathias Schleiden,
Theodor Schwann, Rudolf Virchow and Charles Robin for the establishment of the scientific
basis of cell theory and cell pathology. Conversely, the reduction of disease to the cellular
level only confuses the issue of defining health and disease. Phenomena occurring at lower
levels may provide insights on others pertaining to levels of higher complexity.
THE INDIVIDUAL LEVEL AND THE REALITY OF LESIONS
At the individual level, pathological conditions are detectable through an anamnesis

of signals and symptoms, by laboratory tests and through direct clinical observation. New
and complex apparatus permit us to visualize the interior of the body and normality is
55 56
sometimes reduced to figures To the individual level belongs pathological lesions,
physiological alterations, and often, pain, fear, guilt complex, shame. Lesions can be
analyzed at lower (cellular, molecular) levels, described, photographed and recorded. They
constitute an objective reality.
57
Nohl transcribes for us an illustrative report on necropsies performed (ce qui n'a
pas été sans peine) in Austria in the year 1713, during an epidemic of bubonic plague. It is a
good example of the objective description of pathological findings at the individual level. The
authors of that report, Valentin Gorgias e Franz Antoni Fux, a barber, dissected a certain
number of bodies collected during a single day. Their detailed descriptions illustrate well the
variability of pathological findings in the three individuals. One woman showed no buboes,
pustules, or petechiae, but the liver was hard (racorni) and the spleen, colourless. The
corpse of an adult man (a citoyen) displayed a terrible bubon in the right groin; the liver was
53
54
Bertalanffy, Ludwig. von, General....
55
Canguilhem, Georges, Le normal et le pathologique, Paris, PUF, Presses Universitaires de
France, 1966.
56
Foucault, Michel, Naissance de la clinique. Paris, PUF, Presses Universitaires de France,
1963.
57
Nohl, Johannes, La mort noire, Paris, Payot, 1986
9
hard and viscous (racorni et visqueux). A third corpse presented also a bubo in the right
groin, the liver and spleen, hard, and the stomach had its lining peeled (pelé). This report
was submitted to the College of Medicine as a contribution to the definition or diagnosis of
the plague disease.
The peculiarities mentioned are the individual characteristics or different
manifestations presented by the diseased. If their meaning or explanation varies from time to
time and from a culture or a school of thought to another, their presence is real and the
descriptions of lesions and alterations in organs and tissues are readily recognizable at any
58
time or place . And people died from it. Nowadays it is even possible to identify DNA from
Yersinia pestis, its bacterial agent, from the bone marrow of one of the plague victims of past
epidemics. As for the plague disease, it may occur under three main distinct forms: bubonic,
pneumonic, or septicemic, all three resulting from infection with Yersinia pestis.
Medical reports published in the 19th Century are another example of individual case
histories, recording the day by day observations of a patient. They are detailed descriptions
of the condition and the responses of a patient to the ministrations of their doctors. They
represent detailed personal case studies of success or failure, at the individual level.
POPULATION LEVEL AND ABSTRACT CONSTRUCTION OF DISEASES
While diseased persons are real, diseases are abstract concepts. They are social
constructs. They are collective and composite categories resulting from the sum of combined
observations of individual case histories, recorded in distinct places and at different times.
The full range of possible signals and symptoms are seldom if at all present in a single
patient. The expression a "text-book case" means a paradigmatic example where most
signals are present and a diagnosis is easily made. At this level, diseases show emergent
59
properties. Bergandi draws a clear distinction between collective and emergent properties,
60 61
that appear at this higher level of complexity . Collective properties can be inferred or
deduced from the combined characteristics of all the individuals of a population, as they are
the sum of individual characteristics. Emergent properties arise from the integration of parts.
Rates of mortality and age groups are collective, while signals and symptoms are emergent.
The knowledge of the properties or attributes of phenomena that occur at a lower level does
not make predictable the phenomena detected at a higher level, so that knowledge of
cellular pathology does not immediately discloses symptoms in patients. As we saw,
58
. Herzlich, Claudine et Janine Pierret, Malades d’hier, malades d’ajourd’hui. Paris, Paiot,
1991.
59
60
Mayr, Ernst, The growth of biological thought, Cambridge, Belknap Press, Harvard University
Press, 1987.
10
malformations, fractures, physiological disorders are individual ailments, but contagion,

anomaly, aberration, uniqueness, are peculiar to the population level. A characteristic of the
collective quality of disease descriptions is the frequent use of qualifying expressions like
...in many cases... frequently...it may occur...it was observed that... 62
While at the individual level, those persons that died in Austria in 1713 presented
actual lesions that could be described, figured and recorded, the disease of plague is
collective in essence. An example is the diagnosis adopted by The Pan-American Health
Organization which describes, with several qualifying statements, the disease of plague as a
specific zoonoses that affects rodents and their fleas that transmit the infection to several
animals, including man. This is bubonic plague and it affects more frequently the lymphatic
glands of the inguinal region and less frequently those of the axilar and cervical regions.
Fever is also frequent. All clinical forms, including those where linphoadenopatia is absent,
may develop septicemia.
A person who is infected with one of the influenza viruses will present the signals
and symptoms which are compatible with its own individual health condition, its resistance,
its immunity and the genetic attibutes of the virus itself. Symptoms will vary according to
individual physiological and psychological responses, but the concept or category influenza
will change with the advance, accumulation, and revision of facts and theories and the
progresses in diagnostic techniques.But the concept of influenza will change with the
progress of knowledge, the proposition of new theories and the improvement of diagnostic
techniques.
Societies invest diseases with cultural attributes loaded with prejudices. Herzlich and
63
Pierret give us a practical example of the difference in outlook at the two levels, as they
describe the change in the conception of tuberculosis experienced by a student from
Cameroun living in Paris, before and after he contracted the disease. During the first
interview the student expressed a detached opinion of tuberculosis: a banal thing in France,
and a scourge in Africa. But after he was diagnosed as infected, his whole discourse
changed radically. Instead of a theoretical notion, tuberculosis became a real tragedy for
himself, evoking the specter of death. The socially constructed notion of a disease had
acquired the material quality of a pathological condition.
DISEASES AT THE ECOSYSTEM LEVEL
This is the level where complex ecological and epidemiological phenomena take
place. Medical ecology concerns itself with the web of relationships linking all intervening
61
Ostoya, Paul, Les théries de l'évolution, Paris, Payot, 1951.
62
Organización Panamericana de la Salud, El control de las enfermedades transmisibles en
el hombre, Washington, D. C., 1982.
11
environmental factors - physical, biotic, and social - that affects health, while epidemiology
focus on human populations, and draws from a number of disciplines in search for the
origins and patterns of distribution of diseases. Climate and soil are examples of physical
factors; reservoirs, vectors, pathogenic organisms, plants and animals are part of the biotic
environment; cultural traits and social structures constitute the framework of the social
environment.
An interesting description of an epidemic and the emergent phenomena associated
with it, appears in the famous journal of Daniel Defoe of 1722 64 , who describes the plague
that devastated London at that time. He depicts the widespread contagion, mass hysteria,
solidarity and devotion, egotism, demoralization, and the social disruption which can only
emerge as an outcome of the social interactions in a given environment.
Health and disease at this level may be approached from different angles - including
from the medical point of view, but they are not the exclusive province of health
65
professionals, as Boeckl aptly illustrates. Ecologists, artists, economists, lawyers,
administrators, sociologists and psychologists, among others, concerns themselves with
distinct aspects of epidemics. The widespread occurrence of sub-clinical maladies, infectious
or otherwise, which may or may never be clinically detectable, as well as a genetic
propensity for a condition which may or may not become phenotipically visible, are important
questions that arise at this level of complexity. They are the concern of public health
professionals, health officials and administrators, epidemiologists, and health ecologists.
DEFINING DISEASE
The concepts of health and disease suffers from the association with the social
concepts of normality and abnormality, which are not absolute but relative. In common
parlance, disease means a deviation from the established "norm", consequently abnormal,
with connotations of weirdness, strangeness, repulsiveness, viciousness, sickness,
66
derangement, impairment, and disorder. Landy is a good source for the literature on
cultural approaches to health, illness, and disease.
Georges Canguilhem aptly showed that we use the word "normal" with two distinct
meanings: to denote agreement with an arbitrary "norm" or reference value but also as a
synonym of average or "usual". The normal curve of statistics falls into this second concept.
63
Herzlich, Claudine et Janine Pierret, Malades d’hier...
64
Defoe, Daniel, A journal of the plague year, London, 1722.
65
Boeckl, Christine .M., Images of plague and pestilence: iconography and iconology.
Sixteenth Century essays and studies, Kirksville, Truman State University Press, 2001.
66
Landy, David, ed., Culture, disease, and healing. Studies in medical anthropology. NewYork,
Macmillan, 1977..
12
Many conditions are defined as normal or abnormal according to arbitrary diagnostic criteria,
as in hypertension, diabetes, and high cholesterol. In these cases, health conditions tend to
be reduced to numbers. At the same time, what is common or largely prevalent in a
population tends to be considered normal.
The question of medicalization versus criminalization of "abnormal" social behaviour
complicates this issue. A large body of literature is dedicated to the treatment of social
67 68
deviants in different cultures, and along the history . A broken arm is a broken arm, and
a liability or a physical disability in any culture and at any time in history or prehistory, but
homosexuality is not.
The social views on mental diseases also influence clinician's diagnosis, if not
69
conceptions. Scheff arguments that judging a sick person well is more to be avoided than
judging well a person sick. Except when it comes to mental diseases, which attach a life-long
warning label to people merely suspected to present symptoms.
Regardless of the difficulties involved, a precise definition of disease is important
both for theoretical and practical reasons, as we saw. Life is change, and disease is part of
life: wounds, fractures, aging, and parasitism - a symbiotic type of association between
70
distinct species, is a most common way of life, if not the most common . At the same time,
disease has different meanings according to the level of complexity we apply the term, a fact
that has not been considered in the extensive literature devoted to this problem.
At the individual level, lesions and dysfunctions are real, objectively observed and
diagnosed. At higher levels, disease is a social construct, collective in essence.
71
Contrary to the opinion expressed in a recent paper by Temple et al where this
type of definition is regarded as philosophical and impractical for clinicians, and incapable of
making things simpler in terms of genetic variation, I am confident that the adoption of a
functionalist or ecological point of view will take care of the inconsistencies in current
definitions. Temple et al argue that at the molecular level, an increasing number of genetic
variations are being currently and increasingly described, demanding a revision of present
definitions of disease. But reducing disease to genetic variation is philosophically wrong,
practically confusing and socially dangerous. Clinicians usually reduce disease to a set of
signals and symptoms presented by individuals
To reach a proper understanding, historians, doctors and patients must be aware
that they are talking about things that belongs to different levels of complexity. The patient is
67
Foucault, Michel, Histoire de la folie à l'âge classique, Paris, Gallimard, 1972
68
Rosen, George, Madness in Society. Chapters in the historical sociology of mental illness,
New York, Harper & Row, 1968.
69
Scheff, Thomas, Decision rules, types of error, and their consequences in medical diagnosis.
In Albrecht, G. and P. Higgins, eds, Health, Illness, and Medicine. A reader in medical
sociology, Chicago, Rand McNally, 1979, pp. 313-326.
70
Windsor, Donald A., “Most of the species on Earth are parasites” International Jounal for
Parasitology, volumen 28, Amsterdam, 1998, pp. 1939-1941.
13
worried with his own private and particular condition, while the doctor tries to make a
diagnosis in the same way a zoologist or a botanist does with a specimen under the
microscope: to weight individual variances against general signals and symptoms that agree
with those of a recognized category of disease.
71
Temple, Larissa K.; Robin McLeod; Steven Gallinger; and James Wright,. “Defining
disease ...
14
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18

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On the concept of disease 1

Fernando Dias de Avila-Pires

On the concept of disease*

Author: Fernando Dias de Avila-Pires**

* Acknowledgments: Marcia Grisotti and Márcia Pfuetzenreiter read, discussed, and

O conceito de doença é discutido segundo a Teoria dos Níveis de Complexidade. A

Palavras chave: doença; níveis de complexidade; teoria de sistemas; anacronismo;

Palabras clave: enfermedades; niveles de complejidad, teoría de los sistemas,

On the concept of disease

Disease is a biological process older than man.

FOR A NEW CONCEPT OF DISEASE

THE ANTIQUITY AND THE OBJECTIVE REALITY OF PATHOLOGICAL CONDITIONS

COMPLEXITY THEORY AND A NEW CONCEPT OF HEALTH AND DISEASE.

According to this theory, distinct phenomena emerge at different levels of

THE INDIVIDUAL LEVEL AND THE REALITY OF LESIONS

At the individual level, pathological conditions are detectable through an anamnesis

POPULATION LEVEL AND ABSTRACT CONSTRUCTION OF DISEASES

malformations, fractures, physiological disorders are individual ailments, but contagion,

DISEASES AT THE ECOSYSTEM LEVEL

40. Ostoya, Paul, Les théries de l'évolution, Paris, Payot, 1951.

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