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Illness and its meaning
Kleinman immediately distinguishes illness from disease. The patient experiences a number of symptoms, which in turn cause some degree of suffering. The patient conveys knowledge of this experience to a practitioner, who recasts the illness in terms of theories of disorder. (p. 5) This, according to Kleinman, is disease. It is the healer’s interpretation of the health problem that creates the disease as an "it." This can be referred to as "biological reductionism" in the sense that it is looking at disease as only a biological entity and is isolating it from all social factors. He then introduces sickness as his third distinctive term and defines it as the understanding of a disorder across a population in terms of macrosocial forces. His examples include TB as related to poverty and malnutrition, and tobacco as a contributing factor to the sickness cancer. (p. 6) He discusses various outcomes of illness, and then introduces chronic illness as a continuum of worsening or improving periods. (p. 7) On p.8, we learn illness has meaning on a number of different levels. We must understand those meanings from the point of view of all those who surround a patient. The meanings amplify or dampen symptoms, exaggerate or lessen disability, impede or facilitate treatment. (p. 9) He uses the word "soft" to describe the "devalued, psychosocial concern with meanings" and contrasts it with the "hard, overvalued, technical quest for the control of symptoms." This is a serious failing as it (a) disables the healer and (b) disempowers the chronically ill. (p. 9) Kleinman further discusses the meaning(s) of illness, breaking this down into four categories and discussing two in each chapter. In chapter one, he focuses on symptoms and cultural significance. "The meanings of symptoms are standardized "truths" in a local cultural system," (p. 10). He goes on to give examples and describe the ways we interpret our symptoms based on our cultural background. On p. 16, he sums up the importance of individual differences in the following phrase(s): "…I do not know you well enough to make full sense of your experience. Are you generally stoical, hysterical, hypochondriacal, manipulative? Understanding who you are influences how I interpret your complaints." Specifically on the topic of culture, he makes the statement: "…particular symptoms and disorders are marked with cultural salience in different epochs and societies." (p. 18) He refers to Foucault and comments that "…the process of transformation of meaning that Foucault showed can substantially change the nature of the culturally salient mark certain illnesses impress on the afflicted." He is referring to the sense that illness will mean different things to different people, and thus affect them differently, not only due to individual personality differences, but also to culturally significant variations in people’s socialization and life choices. He also discusses the effects of emotional scars brought about by social stigmas surrounding many diseases. He refers to those scars as an "exoskeleton" and says of it "the carapace of culturally marked illness, a dominant societal symbol that, once applied to a person, spoils radically that individual’s identity and is not easily removed." (p. 22) In chapter two, he opens with his Life World model and describes it in the following way: "…the illness becomes embodied in a particular life trajectory, environed in a concrete life world; (it) soaks up personal and social significance from the world of the sick person; this third type of meaning transfers vital significance from the person’s life to the illness experience." (p. 31) His case study of Alice Alcott is his preferred method of providing an example of this life world meaning. Alice Alcott acknowledged her diabetic condition in stages throughout her life. When diagnosed as a young girl, she hadn’t had to mourn her loss of health, since she was still quite active, happy, and able to carry on her preferred life activities. She kept a positive attitude throughout all the years she battled her medical problems. A setback was seen as temporary and an obstacle to be overcome. While she was aware she was afflicted with the disease, she had not yet had to accept the notion that she was ill. Ill was a condition in which life became meaningless for someone only able to observe, and not to participate. Since Alice was still very involved in pursuing life’s pleasantries, she hardly would have considered herself to be ill. The realization of the severity of her illness came to her gradually over the years when she began to experience permanent health afflictions that were negatively affecting her life. The most recent amputation of her lower leg and foot was the action that would make the difference. She was at last experiencing irreversible, negative changes to her body and her spirit. The providers did not understand this, since she had been diagnosed so long ago, and had handled the presence of ‘the disease’ wonderfully. What they were failing to realize was that Alice was only newly learning to accept her ‘illness’ which was very different from her ‘disease.’ Kleinman’s final meaning concerns the emotions of the patient and their family and how those feelings influence their search for knowledge and answers. There is a need to make sense of such devastating, as well as minor occurrences in life. Patients seek resolutions to their problems, as well as explanations to dilemmas such as "why me" and "what next". The grieving process can be applied to one’s own person where disease, injury, and medical procedure are concerned. Some patients may go through different stages throughout their lives, or simply through different stages of an illness. Alice did not accept diabetes as an illness for a long time until she had allowed herself to feel its affects on her body and her sense of self. At that point, I believe, she began to experience stages of the grieving process. That is the point at which she first began to experience losses associated with her condition. Freund and McGuire speak on many of the same facets of disease and illness. They write of medicalization by societies as a method of control. They discuss the potential downfalls of the ‘company doctor’ as a ‘captive professional.’ They reiterate the complex words of Kleinman in lay terms while discussing reification and distinguishing illness from disease. Like Kleinman, there is a central focus on the chronically ill, and the effect such conditions have on the entire family unit. Much of their arguments mirror Kleinman’s four classifications of illness meanings, as in the example of cultural backgrounds shaping patients’ experiences with and understanding of their illnesses. (pp. 144-5) They discuss pain in much more detail than did Kleinman, analyzing the transference of pain experienced into symptoms expressed. All of the readings are making similar points: there is a distinction between illness and disease, yet very little acknowledgement of that within the medical arena. We have looked at numerous examples of situations in which the person is distinguished from their condition and the effects prove undesirable. There is a need to consider what is implied by a healer and what is inferred by a patient upon making a diagnosis. If we are insinuating illness, we must be clear of our meaning in order to clearly understand patients’ reactions to their condition, both immediately and over time. This is essential to their well being as their condition changes over time.
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