Perceptions of Illness and Healing

Sm. Sci. & Med. 1973, Vol. 7, pp. 787-805. Pergamon Press. Printed in Great Britain.

PERCEPTIONS OF ILLNESS AND HEALING

DONALD A. KENNEDY*

Harvard University School of Public Health, Boston, Mass., U.S.A.

Abstract-Patients, physicians, scientists and public health officials hold variant perceptions of the processes of illness, injury and unnecessary death that afflict human populations. As these different role performers in the field of health care interact, numerous conflicts arise because the full set of operating values and assumptions are not explicitly revealed. Recognition of central variations in orientation and special interest can assist policy formulation and decision- making where cooperative action is required. Significant improvements in health status for specific population groups will be retarded until this deeper level of understanding is achieved.

THERE are diverse patterns of belief and behavior associated with the human response to illness, injury, and premature death. Most of these patterns vary systematically from culture to culture and according to position and role within any given culture. The purpose of this paper is to review the state of knowledge in this general field and to make some suggestions on the transfer of knowledge into practice within the fields of medicine and public health.

ASSUMPTIONS

The following set of assumptions gives both an orientation and a framework for the presentation to follow.

(1) There are approximately 3.6 billion people in the world. Most of them live within the political boundaries of 144 nation states and speak at least one of 159 languages. Because of the universality of experience with death, illness, injury, and handicap, each human group develops specific patterns of behavior and belief to facilitate individual and group adaptation to these disturbing events. (2) The major types of adaptation are: acceptance, escape, prevention, curative treatment, rehabilitation, emergency response, and scientific research. (3) It is a worthwhile scientific activity to compare patterns of health practice and belief among the following groups :

(a) nations and cultures; (b) consumers and providers of health services: (c) different types of health practitioners; (d) biomedical researchers and practitioners.

(4) Analysis of the various patterns may provide new knowledge of use in developing improved techniques of human intervention in the fields of medicine and public health. These new methods of professional practice can be expected to produce discernible improvements in health status for specific populations. (5) There are five major types of health practice operating within most countries of the world. They are: folk medicine, religious medicine, scientific medicine, public safety, and public health. (6) It is assumed that patterns of health practice from each of these five systems will continue to coexist within most countries for an indefinite period of time. (7) Improvement in the health status of families and categories of people can be achieved through greater integration of knowledge and coordination of effective practice among these five health practice systems.

* Lecturer on Health Services Administration, Harvard University School of Public Health, 55 Shattuck Street, Boston, Massachusetts 02115.

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788 DONALD A. KENNEDY

FORMS OF ADAPTATION

The basic orientation of this article focuses upon the issue of adaptation within an ecological framework. As Hughes has argued [ I] :

In speaking of health and well-being we are, essentially, confronting one aspect of the ancient and persistent conceptual problem of adaptation, adjustment, and equilibrium. Dislike it as we may because of the methodological and operational snares involved in use of these terms, we cannot avoid them; for health and well-being are but indicators or phases of the more comprehensive phenomenon, life itself; and life is rooted in processes of adaptational efforts directed at specific environments. . . . Life and adaptation (and therefore health) is, then, a conriizgenr phenomenon, not to be discussed except with reference to the specific conditions of life. One must ask what is adjusting, is attempting to adapt, and to what? . . . . Health and disease- are thus concepts which inherently imply the necessity of considering context, both in terms of definition and of causation. For health is, first of all, rooted in transaction, in the continuous activity on the part of the organism to establish and maintain patterns of relative adaptive success in dealing with its environment, both its external environment and its internal milieu. In this light health, is then, an ecological phenomenon, always to be considered in terms of contextual relations. . . . Life is therefore an expression of a stable, continuing constellation of adaptive processes, and disease represents an exaggerated or abnormal use of defense reactions or mechanisms on the part of the organism in its attempts at adaptation to threatening circumstances, either internal or external.

Within this general frame of reference one can identify at least seven kinds of adaptative behavior. First, there is escape behavior. This refers to patterns of refugee flight from the site of wars, riots, disease epidemics, and natural disasters. On a family scale, it is often seen in divorce, job termination or transfer, and a residential move to a new community or to a foreign country. Decisions on escape behavior are usually made by family units or individual persons. Both employer organizations and government agencies may assist or obstruct some of these patterns of escape activity.

Second, there is precautionary behavior. Men can protect themselves against certain kinds of microbial disease by vaccination and regulation of migration. Various forms of shelter can protect against storm, flood, fire or radioactivity. Injury due to automobile accidents can be prevented by the design of roads and cars and the habit of wearing seat belts. Changes in daily eating and exercise pattern can lead to weight reduction and help to prevent heart disease. Police can act in ways to lessen the threat of riot or criminal assault. Genetic counselling of prospective marriage partners can reduce the probability of congenital handicaps in newborn children. Employment and recreational opportunities can reduce violent behavior among young men in crowded city neighborhoods. Adding chemicals to the public water supply can reduce the frequency of dental caries.

Third, there is emergency response. If an epidemic of infectious disease breaks out, rapid vaccination of the community population can limit the mortality and morbidity from the disease. Poison centers can give immediate information about antibiotics over the telephone. Rescue personnel attached to fire and police units can provide a variety of emergency services. Military and medical personnel can provide considerable assistance to communities that have suffered a natural disaster. Fast response ambulance service coupled with intensive care facilities in local community hospitals can provide life-saving emergency service for persons suffering from heart attacks.

Fourth, there are curative health services. For a limited set of disease and injury conditions there are specific medical, surgical, and psychiatric procedures available to produce amelio- rative or curative results. A relatively safe surgical procedure is available for curing appen- dicitis. Many infections will respond to antibiotic medication. The list of curative capabilities

Perceptions of Illness and Healing 789

grows longer each year. Curative services are often viewed as the near total equivalent of scientific medicine capability in an industrialized society.

Fifth, there are rehabilitative services. These services differ from all of the others in that they are concerned with handicaps for which curative procedures are either not available or were not applied early enough in the natural history of the disease process for individual persons. The aim of rehabilitation services is to gradually increase the level of behavioral functioning or to provide compensation for the handicap where possible. This form of health service can help handicapped people to achieve a maximum degree of independence and acceptance. Such services are used extensively for wounded veterans, for congenitally handicapped persons, for the mentally retarded, and for those who have suffered illnesses that leave lasting deficiencies in the neurological, musculature, or sensory systems of the body.

Sixth, there is scientific research. A more recent societal response in coping with illness is to mobilize scientific effort in the field of biomedical research. There have been many dramatic accomplishments resulting from this endeavor. Biomedical research has produced a host of new products, instruments, and techniques that provide improved intervention capability in many areas of scientific medicine and public health.

Seventh, there is acceptance behavior. Both individuals and groups show considerable variation in their tolerance for suffering, handicap, and premature death. A fatalistic attitude is often found in countries with a high infant mortality rate and a chronic shortage of food. Industrial countries may accept high fatality rates from transport and industrial accidents. Nations may accept warfare, riot control, and capital punishment as acceptable ways of coping with conflict and deviance. The public response to knowledge about the causal relationships between cigarette smoking and lung cancer may be yet another example of acceptance behavior. Patients suffering from negligence or error on the part of a physician may or may not initiate legal action.

All.seven of these adaptative patterns of response to health hazards are found to some degree in all countries of the world. The proportions will differ but representative elements are usually quite evident in most geographic regions.

FIVE HEALTH PRACTICE SYSTEMS At the level of the individual person it must be granted at the outset that there is tremen-

dous variation in the way in which a specific individual reacts to illness, injury or threats to his life. But generalizations are possible concerning that manner in which families, residential communities, and societies generate organized activities to cope with health hazards on a continuing basis. Due to the division of labor within nations, and the specialization among nations in an emergent world society, there are specific groups, organizations, and institutions devoted to one or several of the adaptative patterns described above. Three of these health care practice systems are well known: primitive medicine, scientific medicine, and public health. Two more activity areas are added here because they significantly affect the health status of people. There are: folk medicine and public safety. They are not strictly systems of health care practice in a fully differentiated form. They represent sub-routines or specific components within large organized systems of activity. A comprehensive perspective on health care activity requires their inclusion for reasons that will be developed in the paragraphs to follow.

First, there is scient$c medicine. This is modern medicine as it has evolved in the industrialized nations of the world. Although it contains elements of magic, pragmatic


empiricism, and folk lore, it is an organized activity which places a scientific orientation in the position of highest authority. It is differentiated into three major realms: professional practice, medical education, and medical research. The international mobility of scientific discoveries and scientifically trained physicians is quite evident. All nations do not have to support a major biomedical research enterprise in order to benefit from the discovery of new intervention techniques. Well-trained physicians move from country-to-country as a scarce manpower resource in a world market. And hospital practice of medicine and surgery shows remarkable similarity throughout the world even at this time.

Second, there is primitive medicine or religious medicine. This type of health practice is more ancient than scientific medicine. It is based upon assumptions about supernatural and natural events. It is usually more concerned with the psychosocial context of illness than with the biological content of the disease process. Within this framework disease is assumed to result from: (1) sorcery; (2) breach of taboo; (3) intrusion of a disease object; (4) intrusion of a disease-causing spirit; or (5) loss of soul. The use of magic and ceremonial rituals characterize both its preventive and curative practices. All societies, including the most highly industrialized ones, have healing activities utilizing this ancient body of knowledge and technique.

Third, there is public health practice. This system of care is similar to scientific medicine in its commitment to a scientific orientation. It differs from scientific medicine in its primary concern for population rather than for individuals and its emphasis upon preventive rather than curative or restorative procedure. Most of its important successes have come from manipulations of the physical environment. Construction of sanitary water and sewage systems; vaccination campaigns; construction of adequate housing; education of the general public about personal hygiene; emergency quarantine and vaccination during epidemics : these are the major intervention techniques of public health practice.

All three of these systems of health care have trained personnel and defined treatment settings. The two systems providing services to individual clients have an exchange of money or goods for the treatment services rendered. The primitive medicine system is often regarded as a marginal healing activity, not fully legitimate in many industralized countries. The public health system is closely tied to government agency activity and usually financed by tax monies.

The health status of individuals and families are also affected by two additional activity systems. One is folk medical practice and the other is public safety practice. Folk medicine refers to the illness and treatment behavior engaged in by members of families when they act independently of contact with either primitive or scientific healers or it may be more broadly defined as those beliefs and behaviors in a general population that have implications for helping or hindering the health status of persons living in families or other residential units. The beliefs and practices often vary between ethnic groups and according to socio- economic status. The home is the principal health care setting for folk medical practice. When people first become sick, it is the first treatment setting. Most restricted activity days and bed disability days are spent at home.

Folk medical beliefs and practices have a profound influence upon the health status of all people. The daily round of activity exposes each individual to a sizeable number of health hazards. A complex set of customs and habits have evolved in each human group to encourage success rather than failure in coping with these threats to survival and well- being. All of these patterns of behavior operate each day as precautionary or acceptance modes of adaptation.


When there are indications of injury or illness a set of diagnostic, prognostic, and therapeutic procedures are initiated by the patient in collaboration with friends and kinfolk. The home becomes the first-stage health care setting. The person is released from work, school, and other social responsibilities. If the signs of danger diminish within a few days, the person is defined as recovered and he returns to his normal role behaviors. If the danger signs continue or become more alarming, a request for medical service is made to either a primitive healer or to a physician.

The important point to be remembered is that this daily set of cultural routines and first stage illness behaviors is in operation all the time in every population. Since the initiative for contacting either the primitive or scientific curative systems is in the hands of the patient and his kinsmen, there is a high probability that the state of knowledge about human biology and disease in the general public has a strong limiting affect upon the effectiveness of the primitive and scientific curative systems. Unreasonable expectations and demands can be made in asking for service too late or in demanding attention for trivial or self- limiting conditions.

The relationship between folk medicine and public health practice is somewhat different. Practitioners in public health are granted more initiative than their colleagues in the curative services. They do not have to wait to be called before their technical services can be utilized. But, successful public health practitioners must understand the details of folk medical behavior and the realities of the political process in order to produce effective interventions in preventing illness and injury.

The fifth area of health care practice, public nzfety, is more difficult to define. It refers to a set of social problems that often have a serious health hazard component. These social problems are not usually included in the standard categories of disease nomenclature but they have the same quality of danger that we perceive as the hallmark of illness, injury, and death. A list of such problems would include: warfare, crime, riots, labor strikes, poverty, intergroup prejudice and discrimination, traffic congestion and crowding, delays or errors in the administration of justice, shortages of residential housing, inadequate or ineffective public education, various kinds of addictive behavior (smoking, alcoholism, drug abuse, obesity, gambling), inadequate levels of physical exercise, high level of unemployment, exploitive behavior by special interest groups, faulty design or operation of buildings, transportation vehicles, and equipment, economic conditions of inflation or depression, and major inequalities in the distribution of goods, services, opportunities, and recognition. All of these problems are associated with unnecessary stress, frustration, injury and death. One may quarrel with the inclusion of one of more of the items in the list, but our purpose is to identify activities that pose a threat to health and yet fall outside the traditional boundary conditions of legitimate concern for the professionals and organizations working in the health service field.

Public safety practice is in many ways like folk medicine. It is a component of nearly every major organized activity in the society. Legislatures, government agencies, industrial corporations, business firms, schools, churches, and a host of private organizations make a continuing stream of decisions. Many of these decisions have a public safety dimension for specific target populations. Like the domain of folk medical practice, in public safety practice, there is no explicit jurisdiction or specialized collective effort directed exclusively to the health dimension of the central activity in question. Responsibilities for influence, monitoring, and control are distributed to the four winds among thousands of individuals and groups each pursuing its primary organizational mission.


In an important sense public safety is the reciprocal of folk medicine for it is the health aspect of programs and activities conducted by corporations, institutions, and organized groups as they perform their functions in society. It also represents the growing edge of public health practice. The recent development of expertise in the fields of population science, air pollution control, health services management, radiation protection, and aero- space safety are examples of how public health has extended its scope of concern to cope with new challenges to health in the social environment. Perhaps in the near future the prevention of violent behavior will become defined as part of the field of public health. But there will always remain a large residual of activities in public safety that can never become incorporated into public health practice or any of the other differentiated health service systems. Changes in both folk medicine and public safety are most likely to come from shifts in public opinion, activities of general education, experiences in political action, and circulation of ideas and people.

In summary, then, there are five major areas of health care practice, each with its distinctive knowledge domain and its perspective, value orientation, and cluster of routine actions. These five systems of practice co-exist in most human populations. All have visible effects upon the levels of health and well-being enjoyed by persons, families, and communities. Now we turn to a quite different perspective. What are the differences in perception experienced by the various role players within the major service systems?

PATIENT AND HEALER

The perceptions of illness and the expectations concerning outcome differ sharply between client and professional healer. Both parties to the healing relationship are brought together by a significant set of complementary expectations with reciprocal responsibilities. But the experience feels very different on the two sides of the interaction. The person defined as patient has usually begun to experience a fundamental shift in activity and sensation. There is a narrowing down of attention. There is pain and discomfort within the body. There is often disruption of normal activity. The headache may be too severe to permit driving a car or reading a newspaper. The injury to the leg may not allow normal locomotion. The person entering patienthood becomes concerned with his health in a single-minded way. Most of his usual interests recede from attention. Purposeful action comes to a halt. Socially, the patient now becomes eligible for legitimate exemption from one or more social relationships for an indeterminant period of time.

At the same time, other members of the family and associates in the work setting must assume additional duties. They must adjust their own daily schedules to accommodate to the restricted participation of the person now defined as patient. Such adjustments in the network of interpersonal relationships produce a mixture of emotional states and perceptions. There is frustration generated by the transfer of duties and activities; there is worry about the severity and duration of the condition of illness. Depending upon the specific roles, some members of the family will assume nurturant and caretaking responsibilities. Family members will also assist the patient in making a diagnosis and initiating a plan of treatment. Predictions about duration, severity, and probably outcome will be made. Symptoms will be monitored and adjustments made in the treatment plan.

If the condition persists or intensifies, then outside help will be sought, usually by a member of the family on behalf of the patient. Here the definition of the situation changes. Now a person who is specifically trained to perform professional services for the cure of


disease and the relief of suffering has been asked to join in a contract. In exchange for money or goods a healer is now asked to perform his own set of diagnostic and treatment activities.

But what is the healers perception of this request for attention? His daily cycle of activity is full of interaction with a collective set of patients. A new request for attention simply adds one more person into the schedule of professional activities for the day. The physician, with his collective set of patient care responsibilities, must repeatedly re-adjust his priorities of attention and application of professional effort. When emergencies develop, he must shift his effort. He must leave some patients waiting or ask other health care personnel to assume responsibility for interim caretaking.

With his superior knowledge of human biology and disease, gained through many years of training and experience, the physician brings an important degree of reality to the situation. Malfunction of internal physiological processes produce worry, fear, and anxiety in the patient-largely because of his lack of knowledge about human biology. Since the patient is feeling ill, there is an additional deficiency-his illness interferes with normal perception, sensation, and cognition. On the other hand the physician is well and has superior knowledge. Furthermore, he has the advantage of knowing about populations of patients. He knows the probabilities of outcome for various disease conditions and he knows the current weather map of infectious conditions travelling through the community on any given day.

These experimential conditions pervade the perceptions and behavioral reactions of patients and physicians to each other. In addition, the rules of society add their influence upon belief and behavior. The patient has the initiative in calling the physician. No physician is allowed to recruit patients. Only the layman with his low level of understanding about human biology and disease can place the call for help. His level of knowledge about biology and disease is far less than that of the physician, yet he is the one who makes this important decision. This decision-making rule is fundamental to the relationships between persons with highly technical knowledge and members of the general public.

There have been important studies about this relationship between the physician and the patient. Excellent summaries have been written by David Mechanic [2], Stanley King [3], and Eliot Freidson [4]. Mechanic [5] has emphasized the patterns of illness behavior. He delineates the range of responses to symptoms and to available treatment resources in the following set of variables that affect the help-seeking process of the patient and his associates: (1) visibility, recognizability, or perceptual salience of deviant signs and symptoms; (2) the extent to which the symptoms are perceived as serious or dangerous; (3) the extent to which symptoms disrupt family, work, and other social activities; (4) the frequency of the appearance of the deviant signs or symptoms, their persistence, or their frequency of recurrence; (5) the tolerance threshold of those who are exposed to and evaluate the deviant signs and symptoms; (6) available information, knowledge, and cultural assumptions and understandings of the evaluator; (7) basic needs which lead to autistic (defensive) psychological process (i.e. perceptual processes that distort reality or deny reality); (8) needs competing with illness responses; (9) competing possible interpreta- tions that can be assigned to the symptoms once they are recognized; and (10) availability of treatment resources, physical proximity, and psychological and monetary costs of taking action (included are not only physical distance and costs of time, money, and effort, but also such costs as stigma, social distance, feelings of humiliation, and the like). Mechanic goes on to point out how the perceptions of the physician on these issues may differ significantly from those of the patient and his kinfolk.


Stanley King has assembled similar evidence about the reactions of patients to illness and their encounters with medical care and treatment. He describes the typical physiological effects of illness, the psychological reactions to illness, and the influence of the social require- ments of sick role and social class background. His detailed explication of the main dimensions of psychological reaction are quite valuable. He says :

Needs for attention and sympathetic help often increase in response to illness. The patient is concerned about his illness, not about pain in the abstract, but about his pain. The sharp, stabbing sensation in the lower-right quadrant of the abdomen is a very personal thing to him, not to be regarded impersonally. At the moment it is the center of his world. Most people who are ill not only want attention paid to their trouble, but also wish to be cared for and to have a strong int%tx of positive emotional expression by others, affection, and love. The prescription of tender loving care, comes out of the strong psychogenic needs of the patient himself [6].

King agrees with Lederer that the patient situation is similar in some respects to conditions of early childhood. There is a strong tendency towards emotional regression. The main features of their regression are egocentricity, constriction of interests, emotional dependency, and hypochondriasis. Manifestations of this type of feeling and behavior in a person defined as a patient are considered acceptable and normal. As revealed in studies by Ernest Dichter [7] and his associates, there is a general theme of fear and need for reassurance. The fears are of death, mutilation, incapacity, helplessness, and dependency.

Eliot Freidson has developed a complementary perspective which places major emphasis upon social processes that influence definitions of illness and the beliefs and behaviors of participants. He reminds us that physicians nearly always tend to over-report symptoms and disease conditions and patients nearly always tend to under-report such events. His comments on the interaction between physician and patient are quite instructive on this point :

Given the viewpoints of two worlds, lay and professional, in interaction, they can never be wholly synonymous. And they are always, if only latently, in conflict. . . . Hence, interaction in treatment should be seen as a kind of negotiation as well as a kind of conflict . . . the patient using his symptoms to establish a relationship with the physician . . . likely to want more information than the doctor is willing to give him. . . . . . . just as the doctor struggles to find ways of withholding some kinds of information, so will the patient be- struggling to find ways of gaining access to, or inferring such information. Similarly, just as the doctor has no alternative but to handle his cases conventionally, so the patient will be struggling to determine whether or not he is the exception to conventional rules. And finally, professional healing being an organized practice, the therapist will be struggling to adjust or fit any single case to the convenience of practice (and other patients), while the patient will be struggling to gain a mode of management more specifically fitted to him as an individual irrespective of the demands of the system as a whole. These conflicts in perspective and interest are built into the interaction and are likely to be present to some degree in every situation. They are at the core of interaction, and they reflect the general structural characteristics of illness and its professional treatment as a function of the relations between two distinct worlds, ordered by professional norms [8].

These perceptions are quite significant in understanding what happens in response to illness and within the treatment process. We need to be reminded of this dimension of inherent conflict because of the general tendency to assume that full knowledge, proper education, and more complete communication could eliminate the tensions frequently encountered in the interactions between clients and professional consultants.

DIFFERENT PRACTITIONERS

As indicated earlier, there are different kinds of occupational groups providing health care services. In a fully differentiated form there are practitioners in primitive medicine,


scientific medicine, and in public health. Within each of these generic fields there are a host of occupational specialists. The work of the health practitioners in each of these major fields is guided by a system of perceptions, beliefs, and values about the phenomena associated with illness, injury, and unnecessary death. We shall examine each of the major systems in greater detail at this point.

The basic assumptions associated with primitive medical practice have been succinctly summarized by Erwin Ackerknecht in the following passage:

Disease and death among primitives are in the overwhelming majority of cases not explained by natural causes, but by the action of supernatural forces. In general, the disease mechanisms are: either the intrusion of a disease-producing foreign body or spirit, or the loss of one of the souls which may be abducted or devoured. These mechanisms may be put into motion either by a supernatural agency (God, spirit, etc.) who feels offended, or by a fellow man who avenges himself either by hiring a sorcerer or by himself acting as a sorcerer. Supernatural causes must be discovered by supernatural means, and thus primitive diagnostics consist of various types of divination : bone-throwing, crystal-gazing, trances, etc. The therapeutics cover a whole gamut of methods, reaching from purely matter-of-fact treatments (herbs, massage, bath, etc.), a mixture of such objective methods with magic spells or prayers, to purely magic-religious rites-the mixed treatments probably prevailing in number [9].

The author then continues with a description of the importance of the social relationships

associated with medicine and disease in non-literate cultures. He phrases it this way :

We do not usually associate diseases with whether or not our persona1 relations are good, whether we keep certain religious or social rules or not. But this is exactly what the primitive does. Disease derived from sorcery, from taboo violation, from the anger of ancestral or other spirits is the expression of social tensions. A seemingly independent, biological problem is thus woven into the whole socio-religious fabric in such a way that disease and its healer play a tremendous social role, a role that in our society is assumed rather by judges, priests, soldiers, and policemen [lo].

In such a system of thought as this the threat of disease or death becomes part of the basic system of social control of the society. Not only the patient or sinner is involved in the diagnostic and treatment events but others closely associated with him are participants as well.

Primitive medicine, then, is based primarily upon principles of magic and religion. As Hughes has written:

Therapeutic practices in ethnomedicine addresses themselves to both supernatural and empirical theories of disease causation. Ackerknecht has said that primitive medicine is magic medicine; certainly much of it is, and, insofar as supernatural causes are involved, therapeutic regimes are based on countervailing supernatural powers or events. Thus, the powerful shaman or healer attempts to recover the soul lost or stolen by a human or supernatural agent. The intrusion of a disease object or disease-causing spirit is treated by extraction or exorcism, and diseases which come as punishment for breach of taboo are usually treated by divination or confession of the infraction. Forgiveness and reestablishment of harmony with the moral and supernatural order are thus important outcomes of the therapy [l I].

This is not the full extent of primitive medical practices. There are pragmatic empirical practices as well, for no social group is without its simple medical and surgical practices or the use of plants for medicinal efTect. The knowledge of anatomy is usually very weak but the knowledge of medicinal effects from plants is often quite extensive. Bonesetting, minor forms of surgery, and a range of physical treatments are usually well developed.

796 DOXALD A. KENNEDY

Many of these practices are not anchored in magical reasoning but survive on the grounds of visible cause and effect relationship. The mechanisms of causality may not be understood in detail but the subjective probability associated with successful outcome after the use of a specific herb reinforces the pattern of treatment.

Primitive medicine has a longer history than scientific medicine and public health. It was developed prior to the invention of the scientific method, and it developed in a cultural climate where there was intense human concern and relatively little empirical knowledge about biological processes. Primitive medicine performed multiple functions within small tribal societies with economies based upon hunting and gathering or agriculture.

Perhaps its greatest and most lasting strength is found in those practices that helped the psychological and social responses to illness, injury, and death, for all participants. Even today it provides a reasonable outlet of activity to cope with the anxieties associated with the inherent uncertainty of outcome of the disease process for any given person. Present day scientific medical practice which is so technical and impersonal in its delivery of services is often deficient in this respect.

The patterns of belief and reasoning in scientific medicine differ from primitive medicine. Here the supernatural assumptions are excluded and only those processes of the natural world amenable to scientific observation and experimental study are included. Data obtained through the human senses with the aid of various instruments is combined with principles of logical reasoning to produce public findings that are subject to independent verification by other scientists. This is the knowledge orientation of scientific clinical medicine. Its historic development is of relatively short duration. Only 60 years ago Abraham Flexner urged medicine to adopt a strong scientific orientation. He said:

From the earliest time-s, medicine has been a curious blend of superstitution, empiricism, and that kind of sagacious observation out of which ultimate science is made. . . . The general trend of medicine has been away from magic and empiricism and in the direction of rationality and definiteness [12].

Flexner then went on to define science as the severest effort capable of being made in the direction of purifying, extending, and organizing knowledge. The effort is scientific so long as men strive to transcend their native phenomena in a dry light. He was concerned with emphasizing an orientation, a direction, and a point of view. And he felt that a scientific perspective could characterize both medical research and clinical practice.

This meant that medical practices ought to be tied closely to those fields of scientific study that could yield continuing improvements in clinical performance. In the early first decade of this century, those fields were anatomy, pathology, biochemistry, pharmacology, bacteriology, and physiology. Within the past 25 years biomedical research activities have been greatly expanded with support from charitable foundations and national governments. The life sciences have grown to an impressive level of maturity, and many of the physical sciences and engineering fields have found specialized application in the field of clinical medicine.

In most recent years the behavioral and social sciences have grown to a point where their methods and generalizations are finding increasing application in the professional worlds of medicine and public health. In comparison with the other professions, such as law and architecture, medicine has certainly developed the strongest scientific orientation and provided the strongest institutional arrangements for collaboration between the sciences and the practicing professionals. Societal support for biomedical research has finally achieved a level where we can expect a continuing flow of new discoveries that will constantly


improve the effectiveness of interventions in the health arena. This new knowledge and technology is available to most physicians with a scientific orientation throughout the world.

The reasoning pattern of scientific clinical medicine is characterized by a highly analytic approach, a dominant concern for single-factor etiology, and a preoccupation with biological and biochemical events inside the skin. Patterns of total body function, relationships with the environment, and patterns of behavior or social relationship are only weakly perceived as relevant to the clinical practice of medicine. The central social role of providing healing services to one patient at a time leaves its stamp on most patterns of reasoning in clinical medicine. The highly successful experience in identifying microbes that were specific and singular causes of serious disease produced an intellectual heritage and a trajectory of perception and value that continues to shape most professional actions and perceptions in this field today. The central assumption is that there is a specific virus, bacteria, or genetic deficiency behind each and every one of the many thousands of classified disease conditions. The established treatments are surgery, chemotherapy, exhortation, and reassurance.

The third type of practitioner operates according to the perspective of the field of public health. This field of knowledge and practice is also scientific in its basic orientation. But the central focus is upon prevention of illness and injury in populations, not the cure and rehabilitation of individuals who define themselves as needing medical attention. Leave11 and Clark have described the essential differences in the form of a series of comparisons (see chart, p. 798). One might add an additional point of comparison: the initiative lies with the patient in relationship to the physician and in public health the initiative lies in the hands of the director. The major techniques of intervention in public health are : political, legal, administrative, educational, and by vaccination.

COMPARISON OF PRACTICES [13]

The orientation of public health practice emphasizes prevention and a concern for populations rather than individuals. The central methodologies of public health come from epidemilogy, biostatistics, engineering, and applied behavioral science. There is a strong tendency to use multidisciplinary teams both in research and in practice. There are strong working relationships with a large spectrum of scientific and engineering disciplines. The involvement with the behavioral and social sciences has been much in advance of the field of clinical medicine. The collective or population focus of public health and its central dependence upon political, legal, and educational techniques of intervention has provided both supportive climate for the participation of the social sciences. There is a similar strength of expertise in management, planning, and evaluation of service programs. An understanding of the workings of communities, organizations, and government agencies has been essential for the public health practitioner.

The cognitive style of public health bends in the direction of identifying diseases and environmental conditions hazardous to health in specific populations. The mission is to find means of preventive intervention prior to the appearance of visible symptoms or restricted activity. For nations with high frequency of infectious disease, the interventions of vaccination, sanitary engineering and the application of pesticides have a demonstrated effectiveness. In countries where chronic disease dominate in the epidemiological patterning of mortality and morbidity, the methods of intervention often emphasize educational techniques and modifications of the environment. The frame of reference is ecological.

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Public Health Director Private Practitioner

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10.

He is trained as a specialist in preventive medicine. His primary concern is with the various aspects of prevention. His patient is the community, and his major concern is with disease as it affects groups of people. In numerous instances, of which the health of mothers and children is a good example, the approach to the group must be through individual patients. He seeks health procedures which can be applied economically to large numbers of people with satisfactory results for a high percentage of them. He uses community health education technics to persuade individuals to avail themselves of helpful procedures. He functions through organized community effort and has legal backing if it should be necessary in certain cases. He and his associates are financed by funds coming largely from taxation. He is responsible to the entire community in which he practices his specialty. He has a sort of monopoly in certain aspects of mass preventive medicine in the geographic area in which he works. He must deal with many administrative problems, since his department ordinarily employs a number of people and is a branch of government, and its successful operation requires the cooperation of many agencies and individuals.

Public health practitioners assure that interaction with his environment must be understood in depth in order to identify points of preventive intervention. With the exception of vaccination techniques and health education programs, the bulk of the public health interventions are directed to events and processes in the physical


BIOMEDICAL SCIENTISTS AND PRACTICING PHYSICIANS

The medical schools represent a central intersection for the worlds of biomedical research and the training of practicing clinicians. Every physician, no matter what his career specialization, must pass through this academic setting. Here both students and faculty cope with two competing world views: those associated with scientific research and those associated with clinical practice. There are differences in the requisite patterns of reasoning, action, and criteria for making judgements.

The biomedical scientist is interested in the discovery of new knowledge. His reference group is that set of scientists engaged in research in his field of special interest. These people may be scattered all over the world and may publish their results in several different languages. The scientist is interested in generalizations and in the development of theory; he is not interested in the application of knowledge to a specific person in need of medical services. Furthermore, he is trained to be skeptical about all assertions of factual knowledge. A pattern of organized skepticism motivates scientists to keep testing, challenging, and refining a body of knowledge. Since they are not constrained by the requirement ofproviding an individualized consulting service, they shy away from making decisive statements about clinical problems.

The position of the clinical physician is different. Eliot Freidson has described the difference in the following words:

What is the work of the profession? It is the attempted solution of the concrete problems of individuals . . . it is by its nature applied rather than theoretical in character. . . and markedly different from the work of the scientist. . . . At best, the practicing physician may use general principles to deal with concrete problems: the scientist typically investigates concrete phenomena in order to test, elaborate, or arrive at general principles. Insofar as the practice of medicine it all uses science, it is characteristically oriented to applying rather than creating or contributing to it. Indeed, since its focus is on the practical solution of concrete problems, it is obliged to carry on even when it lacks a scientific justification for its activities. It is oriented to intervention irrespective of the existence of reliable knowledge. . . . Furthermore, medical practice is typically occupied with the problems of individuals rather than of aggregates or statistical units. Probabilities can only guide determination of whether a patient does or does not have a disease. Thus, even when general scientific knowledge may be available, the mere fact of individual variability poses a constant problem for assessment . . . it emphasizes the necessity for personal, first hand examination of every individual case and the difficulty of disposition on some formal, abstract scientific basis [14].

Freidson then goes on to indicate the essential features of the clinical mentality that is associated with the practicing physician :

First, the aim of the practitioner is not knowledge but action. Successful action is preferred, but action with very little chance for success is to be preferred over no action at all. Second, the practitioner is likely to have to believe in what he is doing in order to practice- to believe that what he does good rather than harm, and that what he does makes the difference between success and failure rather than no difference at all. . . Given a commitment to action and practical solution, in the face of ambiguity the practitioner is more likely to manifest a certain will to believe in the value of his actions than to manifest a skeptical detachment. Third, perhaps because of his action orientation, perhaps because of the complexity and variety of the concrete, the practitioner is a fairly crude pragmatist. He is prone to rely on apparent results rather than on theory, and he is prone to tinker if he does not seem to be getting results by conventional means. Fourth, the clinician is prone in time to trust his own accumulation of personal, firsthand experience in preference to abstract principles or book knowledge, particularly in assessing and managing those aspects of his work that cannot be treated routinely. . . . Highest value is placed upon emotional experience . . . widening the range of gut response as a means of


understanding what is going on in oneself and in the patient. This represents a certain subjecti- vism in his approach. And fifth, the practitioner is very prone to emphasize indeterminancy or uncertainty, not the idea of regularity or lawful, scientific behavior. Whether or not that idea faithfully represents actual deficiencies in available knowledge or technique, it does provide the practitioner with a psychological ground from which to justify his pragmatic emphasis on firsthand experience [15].

Each of the roles, scientist and practitioner, produce pressures to perceive, think, reason, and judge events in different ways. The central motivational dynamics and career rewards are different. This is painfully clear in the study of the ethics of clinical research practice where the discovery of new knowledge comes into potential conflict with the rights of the research subject (patient or healthy volunteer) who thinks he is receiving a professional service rather than assuming a risk and making a contribution to knowledge.

The biomedical scientist is guided by a set of norms and values that encourage him to act in a distinctive way. Norman Storer has identified six basic norms. They are as follows :

(1) Universalism

This norm . . . refers both to the assumption that physical laws are everywhere the same and to the principle that the truth and value of a scientific statement is independent of the characteristics of its author. . . .

(2) Organized skepticism

This norm is directive . . . each scientist should be held individually responsible for making sure that previous research by others on which he bases his work is valid. . . . The scientist is obligated also by this norm to make public his criticisms of the work of others when he believes it to be in error.

(3) Communism or communality

This norm directs the scientist to share his findings with other scientists freely and without favor, for knowledge that is not in the public domain cannot be part of the legitimate body of knowledge against which creativity is measured and to which other scientists refer in their work. Further, since other scientists cannot be expected to know what one is working on, this norm encourages the scientist to take the initiative in placing his findings before his fellow scientists.

(4) Disinterestedness

This orientational norm . . . makes it illicit for the scientist to profit personally in any way from his research . . . it prohibits the scientist from making the search for professional recognition his explicit goal . . . it dissuades the scientist from an active interest in doing research as a means toward financial success or gaining prestige in the lay community . . . it serves to make research and discovery an end in itself.

(5) Rationality

Barber defines rationality essentially as a faith in the moral virtue of reason, pointing out that the morality of science tends to drive it into all empirical areas. . . . This goal is based on the moral value that all things must be understood in as abstract and general a fashion as possible. It may be interpreted also as the assumption that necessary to the achievement of the goals of science are: (1) empirical test rather than tradition and (2) a critical approach to all empirical phenomena rather than acceptance of certain phenomena as

exempt from scrutiny.

(6) Emotional neutrality

Emotional neutrality . . . enjoins the scientist to avoid so much emotional involvement in his work that he cannot adopt a new approach or reject an old answer when its tindings suggest that this is necessary, or that he unintentionally distorts his findings in order to support a particular hypothesis [16].

When we compare the two Sets of norms we find some surprising similarities as well as the differences noted by Freidson. Both clinician and scientist must remain emotionally


neutral and disinterested. Both are expected to be rational but one emphasizes the creation of theoretical knowledge while the other stresses the application of a wide range of general knowledge to solve a complex problem embodied in the suffering of a single human being. The clinician is convinced, and properly so, that universal statements of truth are found seriously deficient when they are applied to solving practical problems in the real world. The clinician must eventually assume an authoritative position in reference to a diagnosed condition of illness so he can proceed with therapeutic treatment. His role does not allow him the freedom to remain skeptical or critical of factual propositions for extended or indefinite periods of time. And finally, the clinician is not expected to share the results of his therapeutic experience with patients. The record of his experience with each patient is defined as private and confidential. Satisfactory service to clients rather than the publication of abstract generalizations are the keystone to successful professional performance for the practicing physician.

PERCEPTIONS AND BEHAVIOR Within any geographic setting with its specific cluster of health hazards, the resident

human population has evolved patterns of behavior to assist the imperative processes of adaptation and adjustment. Although patterns of belief and behavior are strongly interconnected, we may judge the behavior patterns as having priority in their relative impact upon the health status of the group. If families typically dispose of human excrement and garbage by burial in the ground, the result is a sanitary environment which reduces the opportunities for insects to breed and thus to transmit infectious diseases, some of which are harmful to man. The reasons given for the burial behavior may be couched in terms of preventing witchcraft, as is the case among the Navaho Indians of the American South- West, or in terms of germ theory interrupting the transmission of infectious disease. The behavior and the pattern of reasoning often vary independently, and the health outcome usually results from the behavior rather than the belief. It is important to recognize this conceptual independence of associations between behavior and belief with reference to health status outcome. Most successful public health and community development programs have had to recognize and utilize this finding.

There is an additional generalization. Patterns of perception, belief, and ideology, are interconnected and tend to form a coherent unity for the social actors concerned. As Kluckhohn has said:

Every groups way of life . . . is a structure-not a haphazard collection of all the different physically possible and functionally effective patterns of belief and action but an interdependent system based upon linked premises and categories whose influence is greater than less because they are seldom brought out into explicit discussion. Some degree of internal coherence which is perceived rather than rationally constructed seems to be. demanded by most of the participants in any culture 1171.

The total context of categories and assumptions about the world tends to permeate each and every activity domain, including health. This finding suggests that all health practitioners must learn the covert assumptions and basic reasoning patterns of their clients. Health professionals are interpreters and intermediaries between a body of scientific knowledge about health enhancement and the realities of folk medicine, primitive medicine, and public safety practice within any given community. To render a valuable and effective professional service, the physician and the public health director must master both worlds of thought and behavior. He must know how providers think and behave; and he must


know how clients believe and act. Continuities and differences between these worlds of perception and behavior are often critical in determining effective performance of the physicians professional duties.

The client must also learn more about these two worlds of thought and action. To an increasing degree, patients must assume a major responsibility for their health status. Many conditions of chronic disease and accidental injury require this. As John Millis has recently written :

. . . the availability and the skill of a physician has very little to do with morbidity from automobile accidents, from cigarette-induced cancer, from alcoholism and its effects, from drug abuse and its results, from obesity, from the lack of self-discipline which sometimes leads to mental and organic disease. . . . The point is that here there are fewer things that the physician can dofir the patient, but there are many things that the patient must do fir himsel The doctor cannot stop the patient from smoking in order to save him from lung cancer. The patient must take the action [18].

This pattern of client responsibility is likely to strengthen in the years ahead. The reasons for this include: (1) the nature of the major health hazards in contemporary behavior settings throughout the world; (2) the unrealistic expectations that many patients have about the intervention capability of the various healers and provider assistants in the field of health care; and (3) the serious shortage of health care services in terms of geography, specialty, or eligibility. All of these trends are likely to continue for the next decade or so. In combina- tion, they place a significant degree of responsibility upon the clients, individually and collectively, to learn new knowledge and skills for preventing illness and coping with injury and disease.

These considerations in turn lead to a serious concern with the concepts of self and other. There is an inherent tendency for all persons to become totally absorbed in their own personal perception of the world. Although evqry social role involves a relationship between two or more parties, individual participants tend to forget the two-sided nature of the interaction. We all tend to neglect a careful consideration of the rather basic differences in perception being experienced by our role partner. As Parsons has recently summarized the central conceptual issue :

The crucial reference points for analyzing interaction are two: (1) that each actor is borh acting agent and object of orientation both to himself, and to the others; and (2) that, as acting agent, he orients to himself and to others and, as object, has meaning to himself and to others, in all of the primary modes or aspects. The actor is knower and object of cognition, utilizer of instrumental means and himself a means, emotionally attached to others and an object of attachment, evaluator and object of evaluation, interpreter of symbols, and himself a symbol 1191.

Illness and injury are events that trigger the most fundamental levels of human meaning and social relationship. The ability to subjectively manipulate perspectives so that one can momentarily take the position of the other and can even enact a convincing performance of the role of the other partner-this ability is needed in situations when there is a threat to health and well being. But no matter how many times we read, write, or talk about this key issue of self-other perspective we still have difficulty living it in daily interactions. Under the impact of the emotional alarm that accompanies illness, we become less competent to manage our thoughts and perceptions-we retreat to an egocentric and one-sided position. It is difficult to generate and maintain empathy in such circumstances. And without empathy there is danger of depersonalization in the delivery of medical services.

There is an additional generalization to be made. The rapid growth of specialization


and division of labor within the health care field has spawned a multitude of tight little cultural islands of knowledge, perspective, and technical language. This process in turn generates the need for integration, synthesis, coordination, and control. As Durkheim pointed out many years ago, the division of labor requires the use of coordinating mechanisms if useful work is to be accomplished. This means that our intellectual quest is increasingly directed toward a search for general principles, rather than additional descrip- tive detail. Clyde Kluckhohn urged the study of implicit culture and values as an approach to this problem. He wrote:

As a result of the accidents of history, every people not only has a sentiment structure which is to some degree unique but also a more or less coherent body of characteristic presuppositions about the world. This last is really a borderland between reason and feeling. And the trouble is that the most critical premises are so often unstated--n by the intellectuals of the group [20]. Cultures or group lifeways do not manifest themselves solely in observable customs and artifacts. There is much more to social and cultural phenomena than immediately meets the ear and eye. If the behavioral facts are to be correctly understood, certain presuppositions constituting what might be termed a philosophy or ideology must also be- known. . . . In a certain deep sense the logic . . . of all members of the human species is the same. It is the premises that are different. Moreover, the premises are learned as part of a cultural tradition. Synthesis within a culture is achieved partly through the overt statement of the dominant conceptions, assumptions, and aspirations of the group in its religious lore, secular thought, and ethical code; and partly through unconscious apperceptive habits, ways of looking at the stream of events that are so taken for granted as seldom or never to be verbalized explicitly. These habitual ways of begging certain questions . . . are distinctive of different cultures . . .[21].

More studies of implicit culture and value orientation need to be made in the health field, especially with reference to the service groups. One gets the impression that we know more about latent assumptions in the area of folk medicine then we do in scientific medicine or public health. Freidsons description of the clinical mentality [22] represents a refresh- ing opening-statement for this field of inquiry but we need more empirical investigations by social scientists from a variety of disciplinary perspectives. People in the United States place high value on activism, mastery over nature, youth, and a future time orientation [23]. Do these values produce specific lacunae in our controlling ideas about health care and biomedical research? Do they help to explain the differential allocation of resources among the specialties of medicine and for different types of health services? These questions and others suggest the strategic importance in studies of implicit culture.

FRAMES OF REFERENCE

There are subtle but profound differences in feeling and action associated with beliefs, attitudes, and values. These images, symbols, and sentiments, acquire their meaning through association with experienced events in the natural world and through their special placement within frameworks of assumption and reasoning [24]. Our whole perspective about a field of knowledge can change when we actively search for a new frame of reference or attempt to compare competing frameworks. This is the case when Hughes [25] argues the case for an ecological perspective in the study of health and disease; Alan Sheldon [26] and his associates apply a general system-a theory approach to the field of health care; Boulding [27] writes about images and the science of iconics or Etizoni [28] describes the active society. As we read one treatise after another our viewpoint shifts and we are tempted to design and then to construct our own frame of reasoning for the same field of empirical events.


The provocative quality of this process can be illustrated by quoting from Freidsons analysis of the medical profession. His basic argument is as follows:

. . . it is useful to think of a profession as an occupation which has assumed a dominant position in a division of labor, so that it gains control over the determination of the substance of its own work. Unlike most occupations, it is autonomous or self-directing. The occupation sustains this special status by its persuasive profession of the extraordinary trustworthiness of its members. The trustworthiness it professes naturally includes ethicality and also knowledgeable skill. In fact, the profession claims to be the most reliable authority on the nature of the reality it deals with. When its characteristic work lies in the attempt to deal with the problems people bring to it, the profession develops its own independent conception of those problems and tries to manage both clients and problems in its own way. In developing its own professional approach, the profession changes the definition and shape of problems as experienced and interpreted by the layman. The laymans problem is recreated as it is managed-a new social reality is created by the profession. It is the autonomous position of the profession in society which permits it to recreate the laymans world [29].

Freidson then goes on to comment about the isolation of the professions:

. . . the characteristics of professional autonomy are such as to give professions a splendid isolation, indeed, the opportunity to develop a protected insularity without peer among occupations lacking the same privilege. This is the critical flaw in professional autonomy: by allowing and encouraging the development of self-sufficient institutions, it develops and maintains in the profession a self-deceiving view of the objectivity and reliability of its knowledge and of the virtues of its members. Furthermore, it encourages the profession to see itself as the sole possessor of knowledge and virtue, to be somewhat suspicious of the technical and moral capacity of other occupations, and to be at best patronizing and at worst contemptuous of its clientele. Protecting the profession from the demands of interaction on a free and equal basis with those in the world outside, its autonomy leads the profession to so distinguish its own virtues from those- outside as to be unable to even perceive the need for, let alone undertake, the self- regulation it promises. I do not mean to deprecate either the real knowledge or the intent of the profession at large. Both its knowledge and its intent are admirable. The problem is that once given its special status, the profession quite naturally forms a perspective of its own, a perspective all the more distorted and narrow by its source in a status answerable to no one but itself. Once the profession forms such a self-sustaining perspective, protected from others perspectives, insulated from the necessity of justifying itself to outsiders, it cannot reasonably be expected to see its self and its mission with clear eyes, nor can it be reasonably expected to assume the perspective of its clientele. _ _ _ Their autonomy has created their narrow perspective and their self-deceiving views of themselves and their work, their conviction that they know best what humanity needs. It is time their autonomy be tempered [30].

The author is challenging several fundamental assumptions that support the legitimacy of the medical profession to continue its traditional role in the delivery of health services in modern society. Evidence is mobilized to support a new kind of understanding about the function of professionals in relation to their clients and to the general public. This paves the way for planning new organizational arrangements in the training and management of physicians as well as other health service personnel. It also provides some imaginative suggestions for further study.

1.

2.

REFERENCES HUGH=, CHARLES C. Health and well-being values in the perspective of sociocultural change. In Comparative Theories of&ciuI Change (edited by PETER, HOLLIS W.) pp. 118-162. Braun & Brumfield, Ann Arbor, Michigan, 1966. MECHANIC, DAVID. Medical Sociology, The Free Press, New York, 1968.


3. KING, STANLEY H. Perceptions of Illness and Medical Practice, Russell Sage Foundation, New York, 1962.

4. FREIDSON, ELIOT. Profession of Medicine, Dodd & Mead, New York, 1970. 5. MECHANIC, DAVID. Medical Sociology, pp. 130-131. The Free Press, New York, 1968. 6. KING, STANLEY. Perceptions of Illness and Medical Practice, pp. 211-212. Russell Sage Foundation,

New York, 1962. 7. DICHTER. ERNEST. A osvcholoaical study of the hospital-patient relationship. Mod. Hosp. 83,

September/ October, 1954. - _ 8. FREIDON, ELIOT. Profession of Medicine, pp. 321-322. Dodd & Mead, New York, 1970. 9. WALSER. H. W. and KOEBLING, H. M. (eds). Erwin H. Ackerknecht: Medicine and Ethnology, p. 19.

Hans Huber, Bern, 1971. IO. ACKERKNECHT, E. H., op. cit., pp. 19-20. Il. HUGHES, CHARLES C. Ethnomedicine. In International Encyclopedia of the Social Sciences, Vol. IO, pp.

87-93. Macmillan, New York, 1968. 12. FLEXNER, ABRAHAM. Medical Education: A Comparafive Study, pp. l-2. Macmillan, New York, 1925. 13. LEAVELL, HUGH and GURNEY CLARK, E. (eds). Preventive Medicine for the Doctor and his Community,

p. 8. McGraw-Hill, New York, 1958. 14. FREIDSON, ELIOT, op. cit., pp. 163-l 64. 15. FREIDSON, ELIOT, op. cit., pp. 168-l 69. 16. STORER, NORMAN. The Social System of Science, pp. 78-80. Holt, Rinehart & Winston, New York,

1966. 17. KLUCKHOHN. CLYDE. The philosophy of the Navaho Indians. In Ideological Difirences and World

Over (edited by NORTHROP;F. S. C.), pp. 356-384. Yale University Press, New Haven, 1949. 18. MILLIS, JOHN. A Rational Public Policy for Medical Education and its Financing, p. 25. National Fund

for Medical Education, New York, 1971. 19. PARSONS, TALCOTT. Social interaction. In International Encyclopedia of the Social Sciences (edited by

SILLS. DAVID). Vol. 10. nn. 42941. Macmillan, New York, 1968. 20. KL&KHOHN,CLYDE. k&or for Man, p. 276. McGraw-Hill, New York, 1949. 21. KLUCKHOHN, CLYDE. Philosophy of the Navaho Indian. Op. cit., pp. 358. 22. FREIDSON, ELIOT, op. cit., pp. 158-184. 23. WILLIAMS, ROBIN M. American Society, 2nd edn, pp. 415-467. Knopf, New York, 1960. 24. NORTHROP, F. S. C. The Logic of the Sciences and the Humanities, pp. 77-101. Macmillan, New York,

1947. 25. HUGHES, CHARLES. Health and well-being values in the perspective of sociocultural change. Op cit. 26. SHELDON, ALAN, BAKER, FRANK and MCLAUGHLIN, CURTIS (eds). Systems and Medical Care. The

MIT Press, Cambridge, Massachusetts, 1970. 27. BC~JLDING, KENNETH E. The Image, University of Michigan Press, Ann Arbor, Michigan, 1961 (Paperback

edition). 28. Enzor+rr, AMITAI. The Active Society. The Free Press, New York, 1968. 29. FREIDSON, ELIOT, op. cit., pp. xvii. 30. FREIDSON, ELIOT, op. cit., pp. 370.

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Perceptions of Illness and Healing

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