Psychiatry in Society
The distribution of health and disease in human populations reflects where people live, how they live, what they eat, the work they do, the air they breathe and the water they drink, their interconnectedness with others, the beliefs they hold about health and disease, and the organization and quality of health care available to them.
The status they occupy in the social order determines their risk for disease, on the one hand, and their access to care, on the other. What they believe guides what they choose from among the options available to them. Because all human disease is social, changed social conditions alter the epidemiology and course of disease.
Among the cultural factors influencing health care is the culture of medicine: the conventional wisdom taught to physicians that guides the actions they carry out. Part of the mystique of medical culture is the convenient fiction that the practice of medicine is simply the application of science to the treatment of disease.
That may be what medicine aims to achieve, but much of daily practice is based on tradition, opinion, anecdote and folklore (for example, what grandmothers “know”: that bed rest is good for the sick person).
Enormous gains in medical knowledge had occurred during that half-century. The new knowledge enabled Beeson torate 60% of the remedies in the first edition as harmful, dubious or at best symptomatic and only 3% as providing fully effective treatment or prevention; by the fourteenth edition, effective regimes had increased sevenfold and dubious ones had decreased by two-thirds.
Despite the sevenfold increase, only a fifth of the remedies listed in this widely used textbook were based on evidence sufficient to establish that they were fully effective. Were Beeson’s study to be repeated today, further positive shifts in those ratios would be recorded, but many treatments in common use today continue to be based on faith rather than evidence.
To demonstrate the impact of cultural beliefs, medical and lay, on the way care is provided, I begin with three illustrations of widespread medical practices which had not a scintilla of evidence to back them. Yet, they were used universally when my medical career began: sanatorium treatment for tuberculosis; complete bed rest for coronary occlusion; and prolonged hospitalization for psychiatric disorders.
All rested on folk belief in the beneficent effects of rest. Then, I turn to diagnostic “fashions” in medicine, jointly shaped by doctors and patients in their efforts to account for distress. Finally, I review the complex relationship between socioeconomic status and disease.
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