To better frame the examples below, I will first provide Canguilhem’s possibly most complete definition of disease that appears in Writings on Medicine, a collection of posthumously republished essays. In an essay entitled ‘Diseases’, he defines diseases as crises that intersect the biological and the social:
Diseases are crises in the growth towards the adult form and structure of the organs and in the maturation of functions of internal self-conservation and adaptation to external demands. They are also crises in the effort undertaken to live up to a model of selected or imposed activities and, in the best cases, to defend the values of or reasons for living (2012, p. 40f).
This definition establishes disease as what disrupts developmental, physiological, behavioral, or psychological norms. By having such a broad definition, Canguilhem is able to meet the naturalist aim of seeing disease as a ‘risk of the living as such’ (2012, p. 35), threatening plants and animals as much as humans. By disrupting these bio-social69 aspects of the living being, disease presents itself, especially with humans, as an ‘existential test’ that ‘provokes an interrogation of the precariousness of organic structures’ (2012, p. 41). Disease is a test in the sense that it reveals what the organism is or is not capable of tolerating. In humans, this undermines our feeling of security as our biological organization is shown to be precarious, our
69 It could be argued that this account is similar to Engel’s (1977) ‘biopsychosocial’ analysis of health and disease.
However, as Canguilhem wants to establish some continuity between the human and biological, the ‘bio-psycho’
aspect seems redundant.
demise inevitable. Canguilhem quotes Freud in saying that disease shows the body’s way of
‘beginning to grow inorganic’ (2012, p. 41). Disease is a trial that tests the organism’s ability, relative to a given milieu, to tolerate having its norms constricted through such varied crises.
By providing this bio-social definition of disease, Canguilhem takes into consideration not only the biological, but also the environmental and social aspects that contribute to this test or ‘experience’ of disease (1989, p. 186). It is because the ‘the physical and social environment, diet, mode and conditions of work, the economic situation and education of different classes’ etc.
(1989, p. 268) all shape organismic norms that the line between anomaly and pathology is best determined relative to ‘a milieu of life and a kind of life’ (2008, p. 128). That such individuality and variability remain a problem for medical judgments is demonstrated through multiple examples that, contrary to Giroux’s critique, actually rely on group or population-level studies.
While these studies reveal aspects that are only visible when comparing populations, it is the fact that disease, whatever its causes, remains an experience of living beings and not of populations that will underscore Canguilhem’s skepticism towards concepts such as ‘public health’.
The first set of examples of the ‘interdependence between nature and culture … in determining human organic norms’ (1989, p. 269) can be found in Canguilhem’s discussion of some international variations in physiological norms. One study discussed is René Porak’s observations of Chinese and Europeans in the 1930s. Porak witnessed how differences in physiological norms, such as urinary discharge, are related to national lifestyle norms. He explained these differences in terms of diet, geography and levels of physical activity relative to the two populations. A similar relativity of norms was witnessed when he tried to use cow’s milk to treat kidney inflammation in some Chinese individuals and observed subsequent urinary irregularities (Canguilhem 1989, p. 168). While we can question Porak’s explanation of this phenomenon as being linked to their cultural view that milk is unsuitable to drink, such culturally shaped physiological differences have since been verified (even intra-culturally within China: cf. Yungfa et al. 1984; Sun et al. 2007), and broadened to explain how the genes associated with lactose absorption became normal as a result of the practice of dairy farming in pastoral societies (Laland, Kendal & Brown 2007)70.
70 While this last study does not focus specifically on Chinese and European populations, it still seems to explain Porak’s observations since lactose intolerance remains the norm throughout China where, with the exception of some groups, dairy consumption and farming are only more recently becoming the norm (Swallow 2003; Myles et al. 2005).
Secondly, Canguilhem discusses a study that revealed the statistical normality of hypoglycemia in African blacks. When compared to European norms, this ‘normality’ would be considered pathological: ‘the black withstands hypoglycemias which would be considered grave if not mortal in a European’ (1989, p. 171). While it could be argued that this physiological normality is what determines these individuals’ modes of life, Canguilhem argues that it is actually the ways of life that determine what becomes statistically normal, in the sense that such physiological norms are likely the result of chronic malnourishment, intestinal parasitism and the presence of malaria. A third example is a study by Otto Klineberg who found differences in average blood pressure between Chinese and Americans and even witnessed changes in blood pressure in Americans who had lived in China for some years and adopted their lifestyle (1989, p. 270). All three examples suggest that the ‘form and functions of the human body are the expression not only of conditions imposed on life by the environment but also of socially adopted modes of living in the environment’ (1989, p. 269). In these examples, species-typicality is not that which determines behavior, but it is behavior, be it of the individual or of a group, that shapes species-typical norms, a process that now goes by the name of ‘gene-culture co-evolution’ (Laland, Odling-Smee & Myles 2010).
To provide further evidence of the role of the environment in determining the distinction between anomalies and pathologies, Canguilhem discusses a study in which an enzymatic deficiency in African blacks was only diagnosed as such when some Africans were living in the United States and receiving antimalarial drugs, such as quinine (1989, p. 282). It was only in the presence of such drugs that the individuals became rather sick and whose deficiency was discovered. However, in the ecological context of Africa such enzymatic deficiencies actually conferred the benefit of resistance to malaria. What determines whether this variation is an anomaly that improves the chances of surviving malaria or whether it becomes a deficiency that can trigger various problems thus depends on the environment in which the individual resides. More recently, the maintenance of this enzymatic deficiency within the African population has been explained in terms of the continued presence of malaria and the survival advantage of having such deficiencies (Nesse & Williams 1994, p. 99). It is the relation between the individual and the environment that seems to determine the biological value of these genetic ‘errors’.
The final example to be discussed is one that best exemplifies Canguilhem’s bio-social account of disease. It is found in Hans Selye’s famous studies in the early and mid-twentieth
century on how repeated stress, in relation to different cultural and ecological factors, affects the form and functioning of the body, particularly the adrenal cortex (Selye 1976; Canguilhem 1989, pp. 30, 271; 2008, p. 130; 2012, p. 39). What Selye’s studies show is that through some kind of stimulus, be it a ‘foreign body, purified hormone, traumatism, pain, repeated emotion, imposed fatigue, etc.’ (Canguilhem 1989, p. 271), an alarm reaction in the body is triggered which entails the secretion of corticosteroids. This reaction is biologically favorable since it allows a stressor to be identified and produces an appropriate response, e.g. what is now called the ‘fight-or-flight response’. Under typical circumstances, the organism’s defense systems identify the response and react to it, but if the aggression increases in intensity or continues then these systems can become desensitized and no longer react, resulting in a pathological situation71: ‘If it is normal, given the role of corticosterone in the organism, that every situation of stress causes a suprarenal reaction, it is conceivable that every prolonged catastrophic comportment could result first in functional disease (e.g., hypertension), and then in a morphological lesion (e.g., a stomach ulcer)’ (2008, p. 130). Canguilhem remarks that this explains the (epidemiological) observation that English populations who lived through the continual air raids of World War II saw an increase in cases of gastric ulcer (1989, p. 30).
Canguilhem also returns to Selye in the essay on diseases in Writings on Medicine so as to provide an example of how one’s place within the social hierarchy and the individual’s representation of it are two more factors contributing to these stress responses (2012, p. 39).
The experience of being devalued within society can produce various stress responses that can lead to or exacerbate the pathological problems just mentioned.
Such an example allows Canguilhem to bring social factors, such as working conditions and class inequality, into his understanding of disease. This has more recently been studied in terms of how health inequalities affect biology (e.g., Brunner 1997, 2007), and what are called the social determinants of disease (Link & Phelan 1995). This should clarify the bio-social definition of disease provided at the beginning of this section, such that we can better see how diseases are part of the lived experiences or activities of concrete organisms taken as a whole, i.e., in relation to their biological, geographical, and even political milieu. This implies that physiological norms are best understood in terms of a complex nexus of ecology and chosen or imposed ways of life: ‘perhaps human physiology is always more or less applied physiology,
71 As will be discussed in chapters 5 and 6, this is recently analyzed in terms of allostasis and allostatic overload (McEwen & Wingfield 2003).
physiology of work, of sport, of leisure, of life at high altitudes, etc., that is, the biological study of man in cultural situations which generate varied aggressions’ (Canguilhem 1989, p. 271).
Similarly to the example of population-level influences on individual experiences, with Selye we see that population-level factors, e.g. one’s situation within a hierarchy, influence the experience of health and disease: stress literally changes the body72.
In all of these examples, health and pathology are relative to the norms of living beings, thus linking these concepts to the practices and activities characteristic of concrete organisms for whom the experience of disease is a lived reality. Since Canguilhem claims that only organisms can be considered sick and since he rejects the claim that societies can be organisms, he is therefore obliged to retain his organism-centered account of disease. With these examples he seems justified in claiming that, contrary to Giroux’s critique (2008, p. 183), ecological, social, and contextual factors, such as social norms or environmental stressors (factors which are only visible by considering the population as a whole) show the relativity of medical norms.
Pathogenic agents or situations may be properties of the population, but their meaning is inseparable from the organisms whose norms are tested by them. The individuality of organisms remains a problem since whether such population-level factors are applicable to any given organism is not merely a matter of where an organism is situated relative to what is statistically normal for that population, but depends on the organism’s unique physiology, behaviors, and relation to its environment. To describe health and disease in terms of experience is to refer to those variations in how organisms live their lives, variations that are themselves a result of the interdependence of nature and culture.