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While the clinical view of the process of becoming a patient may rely on a simple binary transition, the citizen’s perspective of the process can be less straightforward. The words ‘sickness’, ‘illness’ and ‘disease’ are sometimes used interchangeably to refer to someone who is unhealthy. However, there are subtle differences in the meanings which can be ascribed to the three terms.

For example, when Marshall Marinker addressed the 1975 London Medical Group Conference on Iatrogenesis on the topic “Why make people patients?” (three years before Pilowsky’s discussion of illness behaviour) he gave his own view of disease, illness and sickness, the three principle modes of what he referred to as “unhealth”. He described disease as a deviation from a biological norm, “…

Figure 2: Normal and abnormal illness beha- viour After Turner (1987)

a pathological process, most often physical as in throat infection, or cancer of the bronchus, some- times undetermined in origin, as in schizophrenia.” (Marinker, 1975, p. 82). He saw disease as hav- ing objective characteristics – ‘central facts’ – which allowed identification. Illness, for Marinker, was the personal experience of unhealth, which could be present without an associated observable disease; this misaligned state of unhealth was likely to cause distress for the doctor. Finally, he de- scribed sickness as the external, public manifestation of illness which represented a negotiated agreement between the individual and a society which agreed to provide recognition and support. Marinker suggested that the security that sickness provided was greater for acute ailments, for sur- gical interventions, and for the young, rather than for chronic ailments, psychiatric disease, and the elderly (Marinker, 1975).

Arthur Kleinman (1981) had a somewhat different view, and explored the relationship between cul- ture and the healing process. The way in which Kleinman differentiated the three states is summar- ised by Allan Young as follows:

DISEASE refers to abnormalities in the structure and/or function of organs and organ sys- tems; pathological states whether or not they are culturally recognised; the arena of the bio- medical model.

ILLNESS refers to a person’s perceptions and experiences of certain socially disvalued states including, but not limited to, disease.

SICKNESS is a blanket term to label events involving disease and/or illness.

(Young, 1982, p. 264)

According to Andrew Twaddle, disease is defined as ‘‘...a health problem that consists of a physiolo- gical malfunction that results in an actual or potential reduction in physical capacities and/or a re- duced life expectancy’’ (Twaddle, 1994a, p. 8). Ontologically, disease is an organic phenomenon (a physiological event) independent of subjective experience and social conventions. Epistemically, it is measurable by objective means (Twaddle, 1994a, p. 9).

Twaddle defines illness as ‘‘...a subjectively interpreted undesirable state of health. It consists of subjective feeling states (e.g. pain, weakness), perceptions of the adequacy of their bodily function- ing, and/or feelings of competence’’ (Twaddle, 1994a, p. 10). Ontologically, illness, is the subjective feeling state of the individual often referred to as symptoms. Epistemically this can only be directly observed by the subject and indirectly accessed through the individual’s reports.

Sickness is defined by Twaddle as ‘‘...a social identity. It is the poor health or the health problem(s) of an individual defined by others with reference to the social activity of that individual’’ (Twaddle, 1994a, p. 11). Sickness in this sense is a social phenomenon constituting a new set of rights and du- ties. Ontologically Twaddle frames sickness as ‘‘...an event located in society . . . defined by parti- cipation in the social system’’ (1994a, p. 11). Epistemically, sickness is accessed by ‘‘measuring levels of performance with reference to expected social activities when these levels fail to meet social standards ...’’ (1994a, p. 11). Furthermore, Twaddle outlines the temporal relationship between dis-

Figure 3: The disease-illness approach (after Young, 1982)

ease, illness, and sickness. The paradigm case is when a disease leads to illness, which then results in sickness.

In an idealised model of this transition, an individual would self-identify as being ill, receive license from society and the community to be seen as sick, and then visit a physician to have their disease identified and treated. Successful treatment would cause the disease to abate, remove the sickness, and eliminate the individual’s sense of being ill.

This uncertain relationship between ‘unhealth’ and the states of illness, sickness and disease was explored by Wikman, Marklund, & Alexanderson (2005) . They used cross sectional data from comprehensive interview surveys of 3,500 employed and self-employed Swedish people to evaluate perceptions of illness, disease and sickness preventing normal work (“sickness absence”), defining these concepts as follows:

Illness is defined as the ill health the person identifies themselves with, often based on self re- ported mental or physical symptoms. In some cases this may mean only minor or temporary problems, but in other cases self reported illness might include severe health problems or acute suffering. It may include health conditions that limit the person’s ability to lead a nor- mal life. According to this definition illness is seen as a rather wide concept.

Disease, on the other hand, is defined as a condition that is diagnosed by a physician or other medical expert. Ideally, this would include a specific diagnosis according to standardised and systematic diagnostic codes. This would in most cases also mean that the specific condition has a known biomedical cause and often known treatments and cures. However, it should be mentioned that there are several limitations to this ideal in practice. One is the fact that a number of medical diagnoses have to be based on subjective information from the patient concerning pains and feelings. Another limitation is the fact that a number of diagnoses are based on syndromes and complex interrelations between different organ systems and thus are not always very specific.

Sickness is related to a different phenomenon, namely the social role a person with illness or sickness takes or is given in society, in different arenas of life. One type of data concerning a more limited aspect of sickness is that relating to sickness absence from work. Such data are often used to measure social consequences for the person of ill health. Here data on sickness absence will be used to measure sickness. [Emphasis added]

(Wikman et al., 2005, p. 450) The study by Wikman and colleagues confirmed Marinker’s view that the overlap between illness, sickness and disease was imperfect. A large minority of citizens (40%) reported just illness, sickness, or disease without mention of the other two conditions. Others identified two of the three. Only 22% of those with an identified disease also reported both illness and sickness absence. The au- thors used the following diagram to summarise their results:

Figure 4: Relation between illness, disease and sickness absence. Percentage of employed aged 16-64 in Sweden 1998- 2001 (n = 13,387) (Redrawn from Wikman et al., 2005)

And in the real world (as distinct from the objectively measured world of the researcher), the boundaries which separate the ill, the sick and the diseased can be less rigid than those delineated by Wikman et al. Kazem Sadegh-Zadeh (2000) proposed an extension of conventional set theory which reduced the precision with which members of a set were defined (“fuzzy set theory”). In areas where the assignment of set membership is governed by subjective assessments, he proposed that the boundaries of a set should be less rigid. Each member of a set could be assigned a degree to which they belonged to a particular set. In the context of this discussion of illness, sickness and disease, it is helpful to consider the Wikman Venn diagram as representing fuzzy sets with poorly delineated boundaries.

Medical sociology has broadened the market-oriented view of the ill citizen as a rational actor choosing to seek care from a qualified professional. Pescosolido found that the widening range of alternatives for complementary or alternative care, self care and so on reframes the choice to visit a medical practitioners as one path among many, several of which may be pursued concurrently (Pescosolido, 1992, p. 1111). She identifies a range of choices which an individual may make when seeking care:

Table 2: The range of choices for medical care and advice (Pescosolido, 1992, p. 1113)

Option Advisor Examples

Modern medical

practitioners M.D.s, osteopaths (general practitioners; specialists), allied health professions

Physicians, psychiatrists, podiatrists, optometrists, nurses, midwives, opticians, psychologists, druggists, technicians, aides Alternative medical

practitioners "Traditional" healers Faith healers, spiritualists, shamans, curanderos, diviners, herbalists, acupuncturists, bonesetters, granny midwives "Modern" healers Homeopaths, chiropractors, naturopaths,

nutritional consultants, holistic practitioners Nonmedical professionals Social workers Legal agents

Clergymen Supervisors Police, lawyers Lay advisors Family Neighbors Friends Co-

workers, classmates Bosses, teachers, spouse, parents

Other Self-care Non-prescription medicines, self-examination procedures, folk remedies, health foods None

In summary, an individual who is ill does not feel totally well; if news of this unhealth or malady is shared with others in society (family, friends, employers), and the individual is granted license to avoid normal daily activities then she is sick. If a medical practitioner decides that the individual has an identifiable collection of signs, symptoms and test results (‘makes a diagnosis’) the individual has a disease. For an individual, their state of health is not seen as a state of total absence of dis- ease (and of illness and of sickness), but of the individual being well enough to successfully take on his desired daily activities, responsibilities, and projects.

The forgoing discussion of health-seeking and health-preserving behaviour and an individual’s re- course to health services may have fallen victim to the narrowed perspective of an educated elite. Most authors appear to take for granted that an individual in a state of ‘unhealth’ will abandon un- healthy behaviour, and seek attention from a healthcare provider.