The ecology of health

Expenditure on health services throughout the industrial world has got out of hand. In many countries it is increasing so rapidly that, at the current rate, it is a matter of decades rather than centuries before it absorbs the whole of the GNP. Clearly, before this point is reached, drastic action to curb health expenditure is required.

But how is this to be done? It is generally assumed that the problem is one of organisation. Some critics favour the American system of free medical enterprise, others the nationalisation of medical services as in the UK, while others favour some intermediary solution such as that adopted in France.

If one looks into the question a little more deeply, it becomes apparent that the problem is not how our health services should be administered but what sort of services should be provided. Those provided today, based on modern medical science, have failed to deliver the goods.

If they had been successful, levels of health would be rising and we would expect to see a reduction in the number of people consulting a doctor, in the number of working days lost through illness and in the expenditure on medical services. The opposite is of course the case. As Powles writes::

"one of the most striking paradoxes facing the students of modern medical culture lies in the contrast between the enthusiasm associated with current developments and the reality of diminishing returns to health for rapidly increasing efforts." [1]

It is agreed, of course, that modern medicine has increased longevity, but this has been greatly exaggerated. Dr R. Logan, Director of the UK's Medical Research Unit, tells us that "a man today can expect to live three years more than his counterpart in 1841". [2] Most of this improvement however occurred before the introduction of scientific medicine. In the period of rapid increase in expenditure on health improvement, life expectancy has more or less levelled off.

Little has done more to increase the prestige and credibility of modern medical science than its apparent success in eliminating infectious diseases, but this success has proved to be short-lived. We are witnessing today a resurgence of infectious diseases throughout the world, in particular of malaria, gonorrhoea, tuberculosis, pneumonia and cholera, while others such as schistosomiasis and dengue fever are spreading to areas where they were hitherto unknown.

The total impotence of modern medical science to reduce the incidence of the so-called 'diseases of civilisation' - cancer, ischaemic heart disease, diabetes, diverticulitis, peptic ulcer,appendicitis, varicose veins and tooth caries - is apparent to all. Their incidence, in spite of all efforts made by the medical profession, continues to increase along with per capita GNP.

The only realistic conclusion to be derived from all this is that medical science is on the wrong track and that a new health policy is urgently required. But what form should it take? It seems clear that, before we can answer this, we have first to rethink basic concepts such as health, disease, medicine and health services.

What are health and disease

Health, in terms of our technological world-view, is seen as the absence of 'clinical symptoms' and disease as the presence of such symptoms. But what do we mean by 'clinical symptoms'? What are they symptoms of? Presumably of disease but this does not get us very far, because many of the diseases we suffer from are classified purely in terms of their symptoms.

This is true for instance of rheumatism, arthritis and many of the 'diseases of civilisation'. It is also true of psychiatric diseases such aspsychosis, neurosis and schizophrenia. Often too, the 'symptoms' are but those of the normal workings of the body's defence mechanisms rather than of any really pathological state. As Dr Malleson points out,

Over millions of years our bodies and those of our ancestors have perfected defence mechanisms against microbial invasions and noxious chemical substances.These mechanisms are very highly developed. For example, mucus which might be dangerous if it were to accumulate in the trachea is expelled by coughing. Toxic substances in the intestines are eliminated by diarrhoea. Microbial invasion of the body is accompanied by a rise in temperature, which is probably intended to increase the rate at which the defence mechanisms are able to act. To suppress this cough, to prevent this diarrhoea, to reduce this temperature is to counteract essential natural processes. [3]

Yet this is precisely what many medical practices aim at achieving. In this way, they mainly serve to eliminate symptoms and, in doing so, tend to exacerbate the diseases they should be serving to cure.

What is more, if the medicines employed are biologically active, they may also produce side effects and thereby induce diseases where previously there were none. Indeed such 'iatrogenic' diseases, as they are referred to, now make up a substantial proportion of the total disease-load of a modern industrial society.

To treat the symptoms is often futile for another reason. They are often those of a disease that has taken such a hold over an enfeebled patient that, regardless of the medical treatment provided, it must prove fatal. In such conditions, the object of treatment is nothing more than to prolong human life, just for the sake of it, and without any regard for the quality of the life prolonged - an absurd and often immoral enterprise, if we take into account the pain that the patient must suffer as a result of the often drastic treatment needed to keep alive from day to day.

Few people realise what proportion of the national health budget ofan industrial country is spent in this way. According to Professor Ross Hume Hall of McMaster University in Canada, 80 percent of the health budget of that country is devoted to prolonging the lives of patients who, whatever treatment they receive, will die in the next ten months, and in this respect Canada does not appear to be exceptional. [4]

To fight the symptoms of disease is insufficient for yet another reason. The absence of 'clinical symptoms' in a patient cannot necessarily be taken to denote that they are in good health. Some 75 percent of people visiting doctors' surgeries today are said to suffer from no recognisable 'clinical symptoms'. Yet they feel ill and-in some sense of the term-they are ill.

Our view of health and disease

The trouble is that our health policies are the only ones consistent with the world-view that has developed during the course of our industrial age and which colours our thinking on all the basic problems that confront us today. What is more, they are the only ones that lead to the sale of medical hardware and expertise and that are thus 'economic'. For these reasons, they are the only ones that, at present, we seem capable of entertaining.

The thesis of this chapter is that to understand health and disease we must see them in the light of a very different world-view - one which we can perhaps refer to as the 'ecological world-view'. This involves, first of all, looking at them in a much wider context.

Modern medical science, we must remember, like all the other disciplines in terms of which knowledge has been divided, has been developed on the basis of the experience of the industrial era - a period of about 150 years - which is negligible in terms of humankind's total experience on this planet of several million years. It is in terms of this total experience that we must look at the issue of health and disease.

But this is not sufficient. We think of health and disease as it affects humans, but they are not something unique, they are only one particular form of life among very many. General systems theory, over the last 30 years, has shown that living entities (systems, such as molecules, cells, organisms, ecosystems, etc.) which may outwardly appear to be extremely different are, at a certain level of generality, very similar and that, at such a level, their behaviour can be shown to be governed by the same basic laws. It also appears that this principle applies to the method by which living systems are controlled. I shall seek to apply a general systems approach to the problem of health.

Stability

The tendency today is to see life processes as largely random. Though the notion of randomness is subject to different interpretations, it can be construed as designating a state of disorder as opposed to order and goallessness as opposed to directiveness or purposefulness.

This is very misleading. Order and directiveness, the latter being really nothing more than four-dimensional order, are the most fundamental features of the biosphere. Indeed if the biosphere did not possess these qualities it could not be studied by science whose role must be to establish regularities and patterns whose very presence must imply order and directiveness.

Still less could there be a science of cybernetics, the science of control, since to control a process is to keep it on its course or trajectory i.e., in the direction of its goal, the latter concept being taken to be dynamic rather than purely static.

I shall take the goal of life processes to be the achievement of stability. A living system is stable to the extent that it is capable of maintaining its basic structure in the face of possible disturbances. This is another way of saying that it is capable of maintaining its homeostasis (as the term is used by Cannon [5]) in the face of change. This does not mean that a living entity is static, it must change as a means of adapting to environmental changes. But such changes do not occur for the sake of them but as a means of preventing more disruptive changes.

It is only in the light of such theoretical considerations that one can understand what is health. Health in fact can only be seen as the stability of the organism within its social and physical environment. This means that to show that an organism is healthy must mean that it is capable of maintaining its stability in the face of potentially damaging discontinuities. I think that most students of health, who see their subject matter in anything but the very narrow context within which it is presently studied by modern medical science, would agree with a definition of this sort.

It is, for instance, that of Professor Audy who saw health

"as a continuing property potentially measurable by the individual's ability to rally from insults, whether chemical, physical, infectious, psychological or social." [6]

If we define health in this way, then, among other things, our notion of cause-and-effect must be radically modified.

The cause of a disease can no longer be seen to be the immediately antecedent event that triggered it off-the micro-organism for instance that is associated with an infectious disease-but that a constellation of factors has reduced the resistance of the organism to a point at which it falls victim to an insult that would normally induce in it only relatively mild symptoms.

If we see cause and effect in this way, then the criterion for determining whether environmental changes can adversely affect health must also be very different from that which is currently applied. It no longer suffices to determine whether such a change actually gives rise to clinical symptoms but whether it is capable of reducing the overall resistance of living things and hence their stability or health in such a way that they become more vulnerable to other insults.

The object of a health policy must be equally revised. Rather than waging chemical warfare against the vectors of disease i.e. at eliminating symptoms, it should be aimed instead at creating those conditions in which discontinuities are reduced to a minimum and in which people's ability to deal with such discontinuities is maximised.

On that basis, our notion of what, among other things, constitutes a pollutant must be radically modified. The acceptable level of a pollutant in the air we breathe, the food we eat or the water we drink, is not just that at which clinical symptoms occur, but that which might be considered to have an adverse effect however slight, on our ability to counteract the biological effects of any other insult.

As Professor Samuel Epstein of the Department of Environmental Medicine at the University of Illinois in particular has shown, a very large proportion, perhaps as much as 80-90 percent of cancers are caused by exposure to chemicals and radiation. [7] Exposure by itself however does not seem sufficient to trigger off a cancer.

Thus Professor Bryn Bridges of the MRC Cell Mutation Unit at Sussex University points out that in a healthy body, cells damaged by exposure to chemicals tend to be effectively eliminated, [8] indeed, if we consider the thousands of carcinogenic chemicals to which we are now daily exposed, were this mechanism not operative, there would be very many more cases of cancer than there already are.

If this is so, then the present epidemic of cancer is not only due to the increase in the number of chemicals to which we are exposed but to the effect of those chemicals and other factors in reducing our ability to eliminate crippled cells.

Learning to live together

It can be shown that as systems develop via the evolutionary process, so do they become increasingly stable. Thus a pioneer ecosystem is subject to all sorts of discontinuities. These are slowly ironed out as the ecosystem evolves, i.e. as pioneering species are slowly replaced by more advanced ones and as a 'climax' or adult state is achieved.

Climax forests, for example, are subject to few discontinuities. Thus demographic explosions and diebacks which characterise a pioneer ecosystem do not normally occur in a climax forest. Nor do droughts and floods, erosion and desertification.

The same is true of living systems at all levels of organisation. As evolution proceeds, they become better adjusted to the particular ecosystem in which they live and hence to the various forms of life that inhabit it.

Thus it is possible to obtain some idea of the time during which an animal has lived in a specific environment simply by determining to what extent it has learned to live with the other forms of life, including the parasites and micro-organisms, that inhabit it. If it has lived in it a long time, then the diseases that could be caused by such parasites have become endemic. They are relatively mild and their function is simply to kill off the old and the weak, i.e to apply quantitative and qualitative controls on host populations.

Consider the case of myxomatosis. It was a well-established disease among rabbits in Brazil among whom it is endemic and causes but mild symptoms. It was unknown among European rabbits which are of a different genus. When myxomatosis was introduced into Australia in 1950, the European rabbits introduced there were exposed to a virus of which they had no previous experience.

In the first year it killed 99.8 percent of the rabbit population, in the next year the death rate went down to 90 percent, seven years later it had fallen to 25 percent. The rabbit population is clearly learning to live with the virus, and vice versa. The relationship between the rabbit and the virus has thus become progressively more stable.

The same thing has happened to human populations throughout the world, as they have been exposed to parasites of which they have had no previous experience and with which they have gradually learned to live.

The population of the various islands of Polynesia, for instance, was decimated by the diseases brought there by the European colonists. That of the Maoris of New Zealand fell from approximately 160,000 to 30,000, and at one time it was thought that the Maoris would become extinct. That of Tahiti fell from a similar figure to about 7,000; that of the Marquesas, it is estimated, from 100,000 to no more than about 3,000.

However, the Polynesians have adapted to the introduced micro-organisms that have become a new component of their environment. They have, in fact, learned to live with them and their population has correspondingly grown. In New Zealand it is now two to three times its former size.

All this makes it clear that as living systems evolve they become increasingly adapted to their environment, and increasingly stable which means that the incidence of disruptive discontinuities is correspondingly reduced. From this must follow the essential principle that the environment which most favours the health of a living system must be that to which it has been adapted by its evolution and with which it has co-evolved.

That this must be so is quite clear in the case of non-human animals. Thus most of us will admit that a tiger has been adapted by its evolution to living in the jungle. It is clearly the jungle that provides its optimum environment. It is the activities it is capable of indulging in, in the jungle, that best satisfy its physical and psychological requirements. It is the food that it finds there that it most enjoys eating and that best satisfies its biological requirements and the same must be true of all forms of life, including humans. All must best be adapted to the environment with which they have co-evolved.

The corollary of this principle must also be true. Indeed, as the environment of a living thing is made to diverge from that with which it has co-evolved, and hence, to which it has been adapted, so will it become ever less stable, and hence less capable of dealing with discontinuities, in fact, less healthy.

Stephen Boyden has formulated this principle very clearly. He refers to it as the "principle of phylogenetic maladjustment". According to that principle:

"if the conditions of life of an animal deviate from those which prevailed in the environment in which the species evolved, the likelihood is that the animal will be less well suited to the new conditions than to those to which it has become genetically adapted through natural selection and consequently some signs of maladjustment may be anticipated."

Obvious though this principle is, and obvious though its importance, it is seldom referred to in the literature, and consequently its significance seems to have been largely overlooked.

"The term 'phylogenetic maladjustment' (the maladjustment is phylogenetic because it represents a characteristic response of the species to the changed environmental circumstances) then, specifically refers to disorders which represent the reactions of organisms to conditions of life which differ from those to which the species has become genetically adapted in evolution through the processes of natural selection. This principle relates not only to environmental changes of a physiochemical or material nature, such as changes in the quality of food or air, but also to various non-material environmental influences, such as certain social pressures which may affect behaviour." [9]

The optimum environment

What then are the lifestyle and the environment to which humans have been adapted by evolution and which must thereby most favour the maintenance of human health? The answers, however much we may be loath to face it, are those of our Palaeolithic hunter-gatherer ancestors. As Washburn and Lancaster point out,

"the common factors that dominated human evolution and produced homo sapiens were pre-agricultural. Agricultural ways of life have dominated less than one percent of human history and there is no evidence of major biological changes during that period of time... the origin of all common characteristics must be sought in pre-agricultural times." [10]

It is, in fact, easy to see why the lifestyle and environment of hunter-gatherers should have been so favourable. First of all, such people were constantly on the move which means that they were not for long in contact with their own excrement. This reduced their vulnerability to many parasitic diseases. They lived close to nature and had at their disposal a wide diversity of fresh and uncontaminated foodstuffs. The small groups they lived in were dispersed over a wide area, which prevented the spread of diseases from one locality to another.

Such small groups, what is more, were not capable of supporting a viable population of the parasites associated with the major infectious diseases that have become current among urbanised populations. A population of 500,000 people, for instance, is required for the measles virus to survive and propagate itself.

Also, since hunter-gatherer groups could survive without disturbing their biotic environment in any way, they did not interfere with established relationships between parasites and their non-human hosts. Bubonic plague, for instance, developed as a disease of rodents, yellow fever and malaria as diseases of monkeys, rabies of bats. Once we destroyed the habitat of the host animals and modified our own so as to create a new niche for the micro-organisms involved, they were quickly transferred to humans.

Malaria too is transmitted by the anopheles mosquito which originally preyed on monkeys living on the canopy of tropical forests and to which it was well adapted, causing but mild symptoms in the host. However, once the forests were cut down, the mosquitoes had to find alternative hosts and the most generally available were people.

The creation of vast urban conglomerations has provided a perfect niche for burrowing rodents, including the rats that transmit bubonic plague. [11] It has also put us in close contact with parasites that had previously established a stable relationship with the animals we had domesticated. An example is smallpox, a variant of cowpox, which is a disease of cattle.

Large-scale irrigation projects have also provided an ideal habitat for water-borne diseases. The result is the spread of schistosomiasis and malaria, which even the World Health Organisation (WHO) acknowledges to be our doing.

"As he constructs dams, irrigation ditches to alleviate the world's hunger he sets up the ideal conditions for the spread of disease."

In general, with the development of industry, the environment we live in resembles ever less that to which we have been adapted by our evolution. We are forced to live in massive industrial conurbations which bear little resemblance to the living environment in which we evolved.

We live in nuclear families, often truncated ones at that, in a vast atomised society, if indeed we can dignify it with that term - that bears no resemblance to the extended families and other cohesive social groupings within which we have lived over the last few million years.

We eat food that is grown by unnatural processes, making use a host of chemical substances, hormones, antibiotics, pesticides including insecticides, herbicides, nematocides, fungicides, rodenticides, etc. of which residues are to be found in practically all commercially available food today.

Our food is then processed in vast factories with the result that its molecular structure is often totally different from that of the food we have been adapted to eat during the course of our evolution, and it is further contaminated with thousands of other chemicals, emulsifiers, preservatives, anti-oxidants, etc. designed to impart to it those qualities required to increase shelf-life and otherwise improve its commercial viability.

We drink water contaminated with heavy metals and synthetic organic chemicals, including pesticides, which no commercial sewerage works or water purification plants can effectively remove. [13]

We also breathe air that is polluted with lead from petrol, asbestos particles from brake linings, carbon-monoxide and nitrogen-oxides from car exhausts, sulphur-dioxide from chimney flues, radioactive caesium, strontium and plutonium from nuclear tests and a host of other radio-nuclides from the flues of nuclear installations.

It is not surprising that, in such conditions, we should suffer from a whole new range of diseases which, among primitive peoples who lived in their natural habitat, were conspicuous by their absence, nor, in fact, that the incidence of those diseases should vary as it does in direct proportion with per capita GNP i.e., with the extent to which our lifestyle and our environment have diverted from the norm.

These diseases are referred to as the 'diseases of civilisation', for they are the direct result of a host of changes brought to our lifestyle and environment, which, with increasing development and industrialisation, are made to divert ever more radically from those to which we have been adapted by our evolution and which, as Boyden notes, must be the most favourable to the maintenance of our health.

"We can easily think of countless examples of the principle of phylogenetic maladjustment operating in homo sapiens. The traditional 'scourges' of mankind, such as plague and typhus and the great deficiency diseases such as scurvy, beriberi, pellagra and kwashiorkor are all straightforward examples of the principle. An examination of reports on the reasons why patients visit their physicians in the most developed countries in Western society today shows clearly that the majority of the disorders of which they complain fit into this category, and are 'diseases of civilisation', in the sense that they would have been rare or non-existent in primaeval society (e.g. virus infections of the respiratory and alimentary tracts, peptic ulcers, cardiovascular diseases, obesity, diabetes and probably much psycho-neurosis)." [14]

If we have lost sight of this inescapable fact, it is above all because we cannot face its implications. Among other things, it makes nonsense of the very idea of progress, which we have identified with development and indeed with industrialisation - the last phase of development, which consists in bringing about, as systematically and as rapidly as possible, in the name of improving the welfare of humankind, those very changes, that, by their very nature, must cause our environment to divert as much as possible from that to which we have been adapted by our evolution.

It is also because of our blind quasi-religious faith in the omnipotence of science and technology, which, we are told, can, among other things, confer on humans the gift of infinite adaptability. But the changes that they permit are only adaptive if this term is used in a very indiscriminatory manner.

True adaptation must refer to changes that counteract discontinuities by creating the conditions that must reduce their incidence and their seriousness rather than merely suppress their symptoms-changes, in fact, that help increase stability rather than accommodate instability -changes that create the conditions that favour health rather than suppress the symptoms of ill-health. Most of the changes made possible by medical science arethereby not true adaptations.

Consider the response to the epidemic of tooth decay. Primitive people, on the whole, had wonderful teeth. With economic development, however, the state of their teeth has seriously declined. It is generally agreed that this is the result of eating junk foods-in particular sweets, biscuits, cakes and over-refined white bread. Indeed, it is in Scotland, where such a diet is most firmly established, that people have the worst teeth - 40 percent of young Scots who have attained the age of twenty-five have no teeth at all. [15]

Now the only truly adaptive policy for dealing with this problem must be to make people change their diet. However, a modern industrial society that sees everything in terms of short-term economics cannot conceivably do this, as it would mean reducing the sales of the food-processing industry.

Therefore it has to adopt a different strategy and the obvious one is to engage hosts of dentists to extract rotten teeth and replace them with false ones - a strategy which, like any strategy our society is capable of applying, must serve to further increase economic activity, and hence help create conditions still less favourable to our health and the state of our teeth. This is clearly not a real adaptation but, in Boyden's language, a 'pseudo-adaptation'.

The function of pseudo-adaptation is not to deal with the causes of a disease, but only to mask its symptoms. While, since they are part of the pattern of resource-intensive and polluting economic activities that are making our planet an ever less suitable habitat for complex forms of life, to apply them is,in the long run, to increase the incidence of the diseases they are supposed to cure.

The trouble is that just about all our health strategies fall into this category. None of them is truly adaptive, none seeks to create conditions which minimise the incidence of disease, all of them simply seek to apply technological means for masking the symptoms of diseases whose real causes modern medicine cannot address.

Treating the whole not the part

This brings us to another important principle. For a health service to be truly adaptive, for it to treat the causes of disease and hence reduce their incidence and their severity, it would have to treat a population's social and physical environment and its relationship with them and thereby the larger system.

Thus to reduce the incidence of cancer we must above all refrain from exposing our population to all the chemicals that today find their way into the food we eat, the water we drink and the air we breathe. We know that it is exposure to all these chemicals that is a primary cause of cancer.

As already mentioned, serious and objective students of this important subject go so far as to attribute 80-90 percent of cancers to this cause. But to bring about such a change would mean bringing about radical changes to industrial and agricultural practices and indeed to the very priorities of our political and industrial elite, all of which is completely outside the brief of those responsible for our health.

For that reason, the medical establishment in many cases is reluctant to recognise the true causes of cancer. It even refuses to admit that its growing incidence is, in some way, the result of the various changes brought to our lifestyle and our environment by industrial development, and continues to insist that this disease has always been an important cause of death, which is simply not true.

It also grossly exaggerates the contribution to the present cancer epidemic of such factors as the consumption of alcohol and of fats and, of course, smoking-factors which are not directly linked with industrialisation.

It then correspondingly overrates the ability of modem medicine to treat individual cases of cancer. In reality, there is no evidence whatsoever that either surgery or chemotherapy, the only treatments our society can provide (the only ones that are politically expedient and economically viable) are at all effective.

The survival rate of women with breast cancer is the same whether or not they are operated on, while that of people undergoing surgery for lung cancer is less than 1 percent. In the meantime the incidence of cancer goes on increasing from year to year and whereas it previously mainly affected the middle-aged and the elderly it is now also one of the major causes of death in children.

It is indeed ironic to consider the massive efforts made by our health services to treat so totally ineffectively the ever increasing number of cancer victims when our political and industrial leaders are committed to policies that can only further increase the number of the victims.

An effective health service must thereby have an unlimited brief. It must be able to veto government policies in every domain, if such policies can be shown to have an adverse effect on our health. It must, in fact, be able to treat disease at the level of society itself rather than merely at that of the individual.

Holistic treatment

Let us consider some of the obvious advantages of holistic treatment. The first is that the higher the level of organisation at which a disease is treated the smaller need be the human intervention - the more the healing process can be assured by the self-regulating mechanisms of nature.

Indeed, the most successful treatments provided by modem medical science are those that seek to create the optimum conditions within which the healing process can occur on its own. When a surgeon stitches up a wound, for instance, or sets a broken bone, that is all that he is doing. The fact is that science is incapable of replicating the incredibly sophisticated biological healing process which is the product of millions of years of evolutionary 'research and development'.

Nor, for the same reasons, can science replicate the social healing process. It cannot transform delinquents, criminals, vandals and drug-addicts, who are largely the products of disintegrated families and communities, into normal well-adjusted adults. The reason is again the same. Socialisation is the only means of creating well-adjusted individuals and there is no way in which scientists can artificially replicate it in a disintegrated society, in which socialisation can occur but imperfectly.

Our only way of dealing with crime, vandalism, drug addicts, etc. is by engaging more policemen, building more prisons, and installing more burglar alarms and other types of anti-crime gadgetry, i.e. once more by suppressing the symptoms of the disease rather than by addressing its causes.

The only way to cure social deviance is to recreate the conditions in which the socialisation process can occur, thereby leading to the development of healthy families and communities within which the incidence of social deviance would be reduced to a minimum.

Logistics

What is more, to treat the symptoms of the disease rather than the disease itself, in a routine and systematic way, presents insuperable logistical problems. It means providing expensive technological treatments and capital intensive hospitals for the hordes of people who must inevitably fall sick in the increasingly unhealthy environment of a modern industrial society.

Many general practitioners in the United Kingdom see as many as a hundred patients a day. Studies have shown that the average doctor in the National Health Service writes up to one prescription every six minutes. In such conditions there is no way in which doctors can accurately diagnose the 'causes' of their patients' complaints.

All they can do is to dish out biologically active drugs such as antibiotics and cortico-steroids which are likely to have some immediately noticeable effect, hopefully eliminating the patient's symptoms, even though, in the long run, they may prolong the duration of the disease and give rise to all sorts of side-effects.

At the same time, hospitals, in spite of the vast sums of money spent on new ones in the last 30 years, are still incapable of accommodating the increasing number of people who are considered to require hospitalisation, and there is today a permanent waiting list of hundreds of thousands of people.

With the inevitable economic decline that faces us today, ever less money is likely to be available for health services and we shall eventually have to face the inescapable fact that it is financially and hence logistically unfeasible to treat disease at an individual level rather than at that of the society and ecosystem whose degradation is its real cause.

Significantly, it is not only ill health that must be dealt with in this way. None of the basic problems that confront our society today can be solved without bringing about the most radical changes to the society we live in.

Take agriculture. There is no sound agricultural policy that could be introduced without changing all the basic features of our industrial society. That we need smaller farms, that they should be geared to poly-culture as opposed to monoculture, that they should adopt sound rotational methods rather than grow the same crop on the same land year after year, all this we know to be true.

But to create such farms and entitle them to prosper is impossible in our society as it is structured today, and in which overriding political and economic considerations assure that we adopt precisely that form of agriculture that is the least desirable on biological, social and ecological grounds.

Indeed, for it to be possible to reintroduce sound agricultural practices, almost everything within our society must change, including family and social structures, life-styles, education, values, fiscal policies, food distribution networks and international trade.

Of course the very suggestion that a Minister of Health, let alone a mere health practitioner, should be able to change the structure of society and its natural environment as the only means of solving the health problems of individual people, would today be regarded as unrealistic if not downright crazy.

But is the idea all that inconceivable? It undoubtedly is if we consider the problem in the context of today's industrial society. However if we view it in the light of human's total experience on this planet, it is seen to be quite realistic.

Indeed, in primitive societies, and let us not forget that over 95 percent of all people have lived in such societies, health was assured in just that manner. Health practitioners (shamans, diviners, etc) maintained the health of their fellow tribesmen by influencing them to act in the way that maintained their human and non-human environment in the state which, among other things, most favoured the maintenance of human health.

Let us briefly see how this was done. A society's behaviour pattern is based on a particular model of its relationship with its environment, which is usually referred to as its world-view.

The world-view of a tribal society is formulated in a language with which few of us are conversant, that of its mythology, and is concerned with the world of gods or spirits. These are not seen as organised in a random manner, however, but in such a way that the model they constitute reflects people's relationships with their human and non-human environment, on the basis of which, adaptive responses can be mediated.

The spirits can be divided into three broad categories. The first are the ancestral spirits. These have still retained their social identity and are thereby still seen as members of their respective family, lineage group, tribe and society. In this way, their organisation reflects, with extraordinary precision, that of their descendants, and serves to sanctify their social structure and hence to preserve it.

Secondly, there are the spirits of nature. All plants, animals and even physical things, such as rocks and streams are regarded as imbued with spirits. In this way, they too are sanctified, which serves to preserve them or at least to reduce the impact on them of people's otherwise destructive activities.

As is now reasonably well known, primitive hunters, before killing an animal, first prayed to its spirit and to the nature god, whose function it was to protect wild animals from depredations, in order to ask for forgiveness for what they were about to do. The totemic system, whereby a particular clan identified itself with a particular animal, also assured that at least in this clan's territory it was regarded as holy and thereby remained unmolested.

Now to sanctify something is the only cultural device that has ever succeeded in preserving it, a fact that is only too easy to verity empirically in the light of the pathetic failure of just about all the efforts of conservationists to preserve our now desanctified society and its desanctified environment from our increasingly destructive activities.

A society, however, is not alone in its non-human environment. It is surrounded by other, often hostile, social groups. In addition a society does not always display the ideal degree of order, for not all behaviour within it is under control. In other words, it displays some measure of randomness, and thereby contains some anti-social elements. Such elements, together with neighbouring hostile tribes are represented by the third category, namely the evil spirits and witches.

It is to be noted that the world is not seen as composed of spirits in the way in which scientists see the world as being composed of molecules and atoms.

Primitive people do not have a reductionist view of the world. The spirits rather than being components of the biosphere are seen, on the contrary, as being organised in such a way as to reflect its truly hierarchical nature. They represent it at every level of organisation not just the lowest one as the scientific model does.

A further feature of the primitive world-view is that the interrelationships that are seen to exist between the different spirits which control society, its enemies and its natural environment, are closely established by tradition and carefully explained in terms of its mythology. What is more, such interrelationships are constantly brought home to people in songs and other ritual activities. Thus, among the Canelos Quichua Indians of Ecuador, as Whitten tells us:

"Playing flutes, singing songs and telling myths, punctuates discussion of Amasanga (who controls the weather, the thunder and lightning), Nungui (who controls the soil-base for the roots of garden-life and pottery clay) and Sanghui (who controls water) These activities are, among other things, mechanisms for associational, or analogic linking of cosmological and ecosystem knowledge to social rules and breaches, and social dynamics to cosmological premises." [16]

In this respect, the primitive model is also in stark contrast with the scientific model. Rather than being divided up into watertight disciplines between which interrelationships are almost impossible to establish, it is, on the contrary, totally non-disciplinary which, in terms of general systems theory, is required if the model is to permit the mediation of an integrated behaviour pattern as opposed to that mere patchwork of expedients that is the policy of a modern nation state.

It is to be noted that the primitive model is formulated in a language which all can understand. This too is in stark contrast with the scientific world-view, which we so highly prize and which is formulated in an esoteric tongue which only a handful of specialistscan really understand.

This is of particular importance if we consider that stability implies self-regulation. It is cybernetically impossible for a natural system to be governed from the outside, for its goal would thereby be random to it and, hence, to the biosphere of which it is an integral part, and would simply reflect that of the external agencies that were doing the 'controlling', as it does in our industrial society today.

For a system to be self-regulating means, above all, that the behaviour of each sub-system must be subjected to the control of the system as a whole, and this is only possible if all its members both use and understandthe same language, i.e. if the language in terms of which their world-viewis formulated be demotic rather than hieratic. [17]

It is in terms of this world-view that a discontinuity such as a disease is interpreted. Sometimes, it is seen as being caused by the evil spirits that reside in witches or other anti-social elements, or else it is seen as a punishment meted out by the ancestral spirits or the spirits of nature for failure to observe the traditional law and in particular for violating a taboo which, in some cases, is also seen as increasing vulnerability to witches.

A typical example is that of the view of disease entertained by the Luo of East Africa. Among them, as Whisson tells us,

"Sickness is believed to be caused by spirits failing into different categories, the most current being the spirits of the parents or grandparents (vadzimu), spirit elders or ancestral spirits and the witches (muroi). While the intervention of the ancestors might be capricious, the diseases ascribed to them or to God were usually felt to he punishments for the sins of the patients or their families. A man who broke a tribal rule might expect to he punished for it by the ancestors or by God in the form of disease. Any man attacked by disease would therefore feel obliged to examine himself and his relationships with the ancestors. A very minor organic disorder - like several days of constipation - might create a considerable overlay of fear or guilt and reduce the patient to helplessness until the rituals were performed and the ancestors propitiated according to the traditions of the society and the directions of the diviner." [18]

In the Old Testament, as we must recall, a natural disaster whether a famine, an earthquake, an epidemic or an invasion by the Philistines was also invariably attributed to failure on the part of the Jews to worship Jahveh in the correct manner, worse still to worship a rival Baal.

The tendency is for people brought up on the modern scientific values to scoff at such a diagnosis. It is 'unscientific' and hence, in terms of our world-view 'irrational' but let us look at it a little more closely. The rules that govern the behaviour of a primitive society that are justified in terms of its mythology and imposed by public opinion, the Counsel of Elders and the ancestral spirits, are not of a purely random nature. They can in fact be shown to be highly adaptive.

In the light of the empirical evidence this thesis is unassailable since tribal societies, in particular hunter-gatherer groups, have been able to achieve an unparalleled degree of stability within their natural environment in which they could have survived and indeed thrived almost indefinitely if their lifestyles had not been interfered with and their environment annihilated by western man. Such stability is maintained by strict adherence to a set of laws that assures above all the preservation of the social and physical environment that most closely resembles that to which the society has been adapted by its social evolution.

This being so, failure to observe such laws, the breaking of a taboo, for instance, and indeed sinning in general, can only be construed as a violation of precisely that set of laws that assures a society's success, indeed its survival.

To sin is thereby to behave in that way which, in such conditions, must lead to the destabilisation of the individual's relationship with their society and the society's relationship with its environment, and such destabilisation can only be reflected in all sorts of discontinuities of which diseases are but one, this being so, the primitive diagnosis, however quaint the language in which it is formulated, is in fact correct. Indeed, if the behaviour pattern that the gods of a tribal society have sanctified is adaptive, in that it has led to the lowest possible incidence of disease and other discontinuities, then the occurrence of a disease must indeed signify that the society has sinned.

What is more, if the disease, like any other discontinuity, is due to a biological, social or ecological diversion from the optimum, then its cure can only consist in restoring the optimum. This means that if it has been caused by a witch then the activities of the witch must be neutralised, so as to reduce tensions and, at the same time, to reduce those anti-social activities in which a witch may possibly indulge.

If the disease is seen as being caused by violating a taboo then the violators must make amends. In particular, they must make the appropriate sacrifices to their ancestral spirits, fulfil their various ritual obligations to kin, cease killing wild animals over and above those that they are ritually entitled to kill and otherwise refrain from doing things which can impair the proper functioning of the society's cultural pattern within its specific environment.

Of course, such individuals are also treated medicinally. For instance herbs and other traditional medicines may be administered as part of a ceremony and these may often prove effective. But to cure the individual is not the prime object of the treatment. It can even be regarded as mere 'spin-off', the real role of the treatment being to restore the biological or psychological stability of the person affected, by restoring the proper functioning of the biological, social and ecological systems whose disruption is the real cause of the problem.

This is the conclusion of Professor Victor Turner with regard to the Ndembu:

"It seems that the Ndembu 'doctor' sees his task less as curing an individual patient than as remedying the ills of a corporate group. The sickness of a patient is mainly a sign that 'something is rotten' in the corporate body. The patient will notget better until all the tensions and aggressions in the group's interrelations have been brought to light and exposed to ritual treatment. The doctor's task is to tap the various streams of affect associated with these conflicts and with the social and interpersonal disputes in which they are manifested-and to channel them in asocially positive direction. The raw energies of conflict are thus domesticated in the service of the traditional social order." [19]

It is also the conclusion of Professor Reichel Dolmatoff's study of the way the Tukano Indians of Colombia adapt to their environment. A Tukano shaman, as he shows, does not see a disease as the result of a simple biological insult as would a reductionist scientist, but as a socio-ecological imbalance:

"His main concern is about the relationship between society and the supernatural Master of game, fish and wild fruits, on whom depends success in harvesting and who commands many pathogenic agents. To the shaman it is therefore of the essence to diagnose correctly the causes of the illness, to identify the exact quality of the inadequate relationship (be it adultery, overhunting, or any other over-indulgence or waste) and then to redress the balance by communicating with the spirits and by establishing reconciliatory contacts with the game animals. In this way the shaman as a healer of illness does not so much interfere on the individual level, but operates on the level of those supra-individual structures that have been disturbed by the person. To be effective, he has to apply his treatment to the disturbed part of the ecosystem. It might be said then that a Tukano shaman does not have individual patients: his task is to cure a social malfunctioning. The diseased organism of the patient is secondary in importance and will be treated eventually, both empirically and ritually, but what really counts is the re-establishment of the rules that will avoid over-hunting, the depletion of certain plant resources and unchecked population increase. The shaman becomes thus a truly powerful force in the control and management of resources." [20]

In this way, primitive people, by correctly diagnosing diseases as the symptoms of social and ecological maladjustment, whether at the level of the individual, the family, the community or the ecosystem, bring about those changes that will put their society back on its correct course; that which will assure a reduction of the incidence of disease to the unavoidable minimum; i.e. to that level at which disease kills but the old and the sick thereby applying quantitative and qualitative controls on a human population so as to help maintain its long-term viability.

It is essential to realise that it is not just diseases but all discontinuities that are interpreted in this way. Droughts and floods and military reversals, as already intimated, are also seen as signs of socio-ecological instability a thesis that has so far been most forcefully put by Roy Rappaport in his study of the Tsembaga of New Guinea:

"The operation of rituals among the Tsembaga and other Maring helps to maintain an undegraded environment, limits fighting to frequencies which do not endanger the existence of the regional populations, adjusts man-land ratios, facilitates trade, distributes local surpluses of pig throughout the regional population in the form of pork and assures people of high quality protein when they are most in need of it." [21]

As I have already pointed out this self-regulation requires the concentrated action of the whole society. All its parts must contribute actively. Each individual must be actively involved in the rituals that will assure his or her society's stability.

Our modern industrial society cannot function in this way because it has disintegrated into a mass of unrelated and alienated individuals who do not have the capacity to take a real hand in the running of their affairs. In this way we have become totally dependent on external agents of control.

At the same time, our society is so structured that it is impossible to treat a disease at any level higher than that of the individual. Experts in different fields, reared on the specialist knowledge contained within the watertight disciplines into which modem knowledge has been divided, are employed to fulfil carefully defined tasks. Each specialist has a limited brief; he or she cannot venture outside what is considered the legitimate field of activity without venturing on to territory over which some other specialist hold sway.

Not only is this true of the medical profession but even of the Minister of Health. The Minister's territory is well defined. He or she can order the building of more hospitals, subsidise the production of more pharmaceutical preparations and encourage the recruiting of more doctors and nurses. The Minister can also bring about certain changes to the Organisation of his or her departments, but that is about all. Against the real causes of disease the Minister can do nothing.

What is more it is difficult to see how, within our modern society the present state of affairs can possibly be remedied. Our society is committed to a course - that of further development and industrialisation - that can only exacerbate all the basic problems that confront it, including the growing ill-health of its members.

In the long run of course, the problem will be solved, for conditions are becoming ever less propitious to the industrial process, so much so that we are faced in the not too distant future with inevitable socio-economic collapse. It is only then that our health could take a turn for the better, for out of the ruins of our industrial society, we can hope to see emerge smaller, more decentralised societies that might eventually develop the capacity for cultural self-regulation and thereby create conditions that are more favourable to the maintenance of human health as well as that of whatever forms of life may have survived the industrial holocaust.

References