Folk illness and medical models

Sometimes an author manages to capture the essence of an article with such an arresting name that you feel compelled to read it. A few years ago I was scanning a list of references when I came across a title so striking that I went to a library at once, to read through the article in question and see if it lived up to its promise. It was called: ‘Hyper-Tension: a folk illness with a medical name’.1 The author of the paper was the American social anthropologist Dan Blumhagen. I was not disappointed. I now regard it as one of the most enlightening pieces of social science research that I have ever read. And although it is nearly a quarter of a century old—an aeon in terms of most academic writing—I still regularly use it as a set text when teaching groups of doctors and asking them to think about their patients’ medical ideas, and their own. Blumhagen reported on how he interviewed 117 men attending a hypertension clinic over a period of 12 months, in order to establish their beliefs about the condition. He found that each person appeared to have an individual model of what had caused their hypertension, together with a collection of ideas about how their body had reacted, and a further set of ideas about symptoms and risks. For example, in one typical individual the causes of hypertension included ‘family arguments’, the physical reaction was described as ‘ballooning veins’, the symptoms were felt as ‘dizzy spells and flashing lights’, and the patient feared the possibility of a ruptured blood vessel, leading to ‘loss of a kidney’. Blumhagen found that many of these individual models seemed to have a great deal in common, so that he was able to draw up a visual map of the ‘folk illness’, linking together fifty-seven concepts such as ‘acute stress’, ‘narrowed blood vessels’, ‘heart attack’ and so forth, with arrows of various thickness indicating the direction of causation as understood by a significant number of people. No doctor who treats hypertension will be surprised by these findings, particularly the strong belief that the patients seemed to have in the psychosocial origins of the condition, and the even commoner belief that hypertension is symptomatic. But the real fascination of Blumhagen’s work is in the discussion that surrounds these findings. It is impossible to do full justice to this here, not least because the article is thirty pages long, but a few indications of the argument may give an impression of its richness. Firstly, Blumhagen challenges the idea that ‘folk’ beliefs are entirely separate from ‘formal’ medical ones. He proposes instead that the two are closely interdependent, the popular condition of ‘hyper-tension’ clearly echoing the expert one, while at the same drawing on associations with more familiar words such as ‘tension’ and ‘pressure’. He also demonstrates how individual illness beliefs are often inconsistent or may change rapidly. For instance, someone might describe ‘stress’ as a cause of their hypertension, yet later in the same conversation, when focussing on a different aspect of their experience, describe it as a consequence. Or alternatively, as Blumhagen says, ‘if one inquires about the physical causes of an illness, an explanatory model may be given which will be radically different from the explanatory model given by the same individual if one then asks about the spiritual or social causes of the same illness’. In other words, what patients bring us when they talk about their illnesses is not some rigid and fully considered theory, but rather a loosely connected and fluctuating bundle of ideas, apprehensions and word associations, often oriented towards justifying a particular aspect of behaviour (for example, taking pills or not taking them, working hard or taking early retirement, and so on). All of this certainly helps to make sense of what goes on in everyday consultations, not just with hypertension but with many other conditions. However, the main challenge that Blumhagen presents is to propose that the official medical model of hypertension may actually bear a great deal of resemblance to the folk version. He shows, for example, how the published medical literature presents a constant reworking of our professional models and belief systems, so that obsolete ideas slide imperceptibly out of view as if they had never been there, while new ones are written into the story in their place—each successive version being presented, of course, as ultimately authoritative. Similarly, he demonstrates how different practitioners present their patients with versions of the ‘facts’ that are highly personal and selective in terms of what they include, omit or emphasize. Such explanations, although delivered with great professional conviction, mainly seem to serve the purpose of supporting the advice or treatment the doctor has already decided to give. These explanations also contain the same inconsistencies that you find with patients: for instance, a doctor might at one moment reassure someone that high blood pressure is unrelated to a stressful life style, while in the next breath offering the standard inane advice to ‘try to relax more’ or to ‘avoid stress’. Social scientists often tend to write about medicine in a way that can leave the ordinary jobbing doctor with a sense of futility and a wish to phone the pensions agency at the first opportunity, but surprisingly Blumhagen ends on a more positive note: ‘Plain folk say “Hyper-Tension”; the experts say hypertension, and each thinks the other is talking about the same thing. Perhaps it is this muddying of the waters which allows both to function without cognitive dissonance becoming so great as to cut off interaction … But there are occasions when dissonance caused by different models of illness does impede healing. At those times, a full understanding of the illness belief systems which are available to the layman and to the physician, if coupled with a willingness to negotiate a more functional set of explanatory models, may pave the way to a richer, deeper and above all more satisfying experience to healing’.

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