Chronic Illness

Sickness and death historically were caused mostly by poor nutrition, inadequate housing, unsanitary living conditions, poverty, warfare and—as population density and urbanization grew—exposure to bacteria, parasites, and communicable diseases. These conditions gave rise to acute illnesses such as influenza, scarlet fever, whooping cough, polio, pneumonia, and tuberculosis. In most cases, acute illnesses occur suddenly and are characterized by a sharp increase in discomfort and pain due to an inflammation, and are of short duration. Whether endemic or epidemic, these illnesses contributed heavily to the high mortality rates and short life spans among persons living in pre-industrial societies. Notable among acute, communicable diseases was the bubonic plague, which caused more than 20 million deaths in Europe between 1340 and 1750 (Cockerham 2001). Prior to the 1900s, acute health conditions rarely could be treated successfully by medical therapies, so they were self-limiting, as they led to either spontaneous recovery or to death within a fairly short period of time. Access to doctors was limited, as were effective medical therapies, so families usually took care of their own sick members; however, the duration of that care tended to be relatively short. By the 1700s, however, industrialization, modernization, new medical technologies, and public health measures were transforming the lives of people living in many Western countries. These forces eventually restructured the workplace, produced a system of monopoly capitalism based on class and wealth, and created a global economy dominated by a handful of industrialized nations. One result of this uneven level of economic development has been substantial disparities in wealth and health among populations living in developed countries and those living in less developed, or developing countries.

In its early stages, industrialization resulted in a rapid deterioration in the living standards and working conditions of most people living in Western countries. Traditional families and economic systems were disrupted as populations migrated into urban areas in pursuit of employment. The lack of clean water and sanitation, the spread of environmental toxins, population concentration, malnutrition, and the nature of industrial work increased sickness and death from contagious diseases. Gradually, public health measures and improvements in diet, housing, water supplies, and sanitation reduced the spread of deadly diseases in these countries. However, as their economic and military dominance grew, industrialized countries rapidly gained control over many underdeveloped countries. Through colonialism and the exploitation of material and human resources, these countries lost control of their economies and suffered dramatic increases in infectious diseases and death. Today, level of economic development has become a major predictor of patterns of health, illness, and death: People living in developed countries usually have better health profiles and longer life spans than those living in developing countries. Life expectancy at birth now ranges from a high of more than eighty years of age in developed countries to less than fifty years in some developing countries (Population Reference Bureau 1998). This gap in life expectancy is largely due to the fact that people in developing countries are still disproportionately affected by acute, infectious, and/or parasitic illnesses that lead to early death. Only about 1 percent of people in developed countries die from infectious and parasitic diseases, compared to 43 percent of those in less developed nations (Weitz 2001).

People in developed countries have experienced the "epidemiological transition"—a shift in the disease burden from high rates of death from acute, parasitic, infectious diseases, and short life expectancy to longer life expectancy and high rates of chronic diseases. The first phase of the transition consisted of improvements in hygiene, sanitation, living conditions, and nutrition, which curtailed the spread of contagious disease. Many less developed societies (e.g., Sri Lanka, Cuba, Costa Rica, Kerala, and China) have substantially increased life expectancies through these measures, and by providing greater education, independence, and family planning resources to women (Caldwell 1993; Hertzman and Siddiqi 2000). The second phase in the transition was the rise of scientific medicine. Medical inventions and discoveries during the mid-1800s, especially in Germany and Austria, led scientists and physicians to reformulate the problem of disease and focus on medical intervention to heal diseases. Rudolf Virchow's discovery of cellular pathology was a major breakthrough, as was Robert Koch's and Louis Pasteur's confirmed the link between bacteria and illnesses (Cockerham 2001). At that time tuberculosis, known as the "white plague," was still the leading cause of sickness and death in Europe and the United States. Koch isolated the germ that caused tuberculosis and Pasteur, proving that many diseases were caused by the spread of bacteria, advanced the use of vaccinations to prevent diseases.

Advances in medical science, the development of more accurate diagnostic technologies, and use of antiseptic surgery, gave birth to modern scientific medicine. The germ theory of sickness became the basis of medical practice and the medical approach to dealing with disease. Scientific medicine's success at reducing infectious disease generated great enthusiasm that a cure for virtually all diseases would eventually be found. Pursuit of the "magic bullets" of medicine, or drugs that would "miraculously" heal diseases, became the focus on medical science. Control over contagious diseases and the germ theory of sickness gave rise to a specific conceptualization of health and illness described as the medical model of disease. The medical model of disease assumes there is a sharp and clear distinction between illness and health, based on the belief that sickness can be readily detected by diagnostic tests and confirmed by physicians. Because it is based on acute, infectious diseases, this model also assumes that diseases have specific causes and clearly distinguishing characteristics, and that they can be healed by medical therapies (Mishler 1981).

The development of modern medicine, combined with an expansion of industrialization and specialization, directly affected families in Western nations. Families in agricultural societies were typically large and multi-functional entities that emphasized economic self-sufficiency through the productive labor of all family members. Industrialization, however, moved economic production from homes to factories, excluded women from the workforce, and created the ideology of the breadwinner-homemaker family as best suited to the needs of the industrial economy. One of the most important changes was the loss of family functions. Families were redefined as specialized institutions with two important functions: raising children and meeting the emotional needs of its members. The modern nuclear family was seen as too small and emotionally bonded to effectively care for their sick members, and it was admonished to leave medical care in the hands of professionals. Talcott Parsons, a leading sociologist of the 1950s, argued that the use of physicians and hospital care was functional for families in that it protected them from the disruptive aspects of illness and helped motivate the sick person to get well (Parsons and Fox 1952). Parsons's family theory was consistent with his concept of the sick role, which described the social expectations governing the behavior of sick persons. Essentially, sick people were seen as exempt from their usual social responsibilities but obliged to try to get well, specifically by seeking competent medical advice and complying with medical treatments. The sick-role concept reinforced the medical model by assuming that illness was a temporary departure from health that was best handled by doctors and health care institutions. By the 1960s, however, these theories were being challenged by the growing prevalence of long-term, chronic health conditions.