Académique Documents
Professionnel Documents
Culture Documents
of
MEDICINE
Perspective
june 21, 2012
2 0 0 TH ANNIVERSARY AR TICLE
PERSPE C T I V E
PERSPECTIVE
The material and conceptual dynamism of disease poses challenges: how do we define disease
meaningfully, and how do we
measure our burden of disease
and set health policy priorities?
These are deceptively simple
questions. The definition of disease in Merriam-Websters Medical
Dictionary as an impairment of
the normal state of the living
animal or plant body raises
questions: What is normal? What
is impaired? We cannot answer
by referencing biology alone: the
line between the normal and the
pathological requires value judgments. As physicians know, not
every symptom constitutes a disease. Nor, as anthropologists have
shown, is it feasible simply to
contrast disease, as diagnosed
by doctors, with illness, as experienced by patients.1 As contemporary disputes over the definitions of alcoholism, chronic
fatigue syndrome, and attentiondeficit disorder make clear, physicians are never the sole arbiters
of disease.
Causes of Death in 1811. Abstract of the Bill of Mortality for the Town of Boston.
From 1812h.
AUTHOR
Jones
RETAKE
1st
ICM
Any responsible
attempt to litical and economic
stakes ex2nd
REG F FIGURE 1
3rd
define disease
must
account
for
plain
the
fierce
debates
that erupt
CASE
TITLE
Revised
EMail
the phenomenons
complexity. ALine over4-Cthe definition of such condiSIZE
ARTIST: mstsignsH/T tions
H/T
disease has Enon
characteristic
as chronic
fatigue syndrome
281pts
FILL
Combo
and symptoms, afflicts particu- and Gulf War syndrome. Disease
AUTHOR, PLEASE NOTE:
lar groups of people,
and
is ahas
deeply
social process. Its disFigure has
beenfollows
redrawn and type
been reset.
check carefully.
a characteristic course. Please
Doctors
tribution lays bare societys strucname diseases and work to iden- tures of wealth and power, and
JOB: 36625
ISSUE: 6-21-12
tify their causes and develop the responses it elicits illuminate
ways to prevent and treat them. strongly held values.4
But patients also ascribe meanThe complexities and conseing to their suffering and assign quences of disease extend to its
responsibility for what went measurement. Even after a diswrong.2 And diseases have utili- ease has been clearly defined,
ty, with concrete consequences measuring its frequency, intensity,
for patients, doctors, and their and relevance is not simple. Since
institutions.3 They mediate pa- the 17th century, polities have
tients claims to the sick role and compiled causes of death into
adjudicate access to health care annual bills of mortality. Succesresources. Disease definitions sive generations of demographers
structure the practice of health and epidemiologists have transcare, its reimbursement systems, formed such statistics into ageand our debates about health adjusted measures of disease-spepolicies and priorities. These po- cific mortality and developed
2335
PERSPE C T I V E
1100
1000
900
No. of Deaths/100,000
800
Diphtheria, 40.3
Senility, 50.2
Cancer, 64.0
Accidents, 72.3
Nephropathies, 88.6
700
Cerebrovascular
disease, 106.9
600
Heart disease,
137.4
500
400
300
Suicide, 12.2
Pneumonia or influenza, 16.2
Nephropathies, 16.3
Diabetes, 22.3
Alzheimers disease, 27.0
Accidents, 38.2
Cerebrovascular disease, 41.8
Noninfectious airways
diseases, 44.6
Gastrointestinal
infections,
142.7
Tuberculosis,
194.4
Cancer,
185.9
Pneumonia
or influenza,
202.2
Heart disease,
192.9
1900
2010
200
100
0
An interactive
graphic showing
causes of death from
1900 through 2010 is
available at NEJM.org
2336
PERSPECTIVE
PERSPE C T I V E