BYRO N J. GOO D
THE HEA RT O F W HAT 'S THE M A T TER
The Semantics of Illness in Iran'
ABSTRACT. Our understanding of the psychosocial and cultural dimensions of disease and illness is limited not merely by a lack of empirical knowledge but also by an inadequate medical semantics. The empiricist theories of medical language commonly employed both by comparative ethnosemantic studies and by medical theory are unable to account for the integration of illness and the language of high medical traditions into distinctive social and symbolic contexts. A semantic network analysis conceives the meaning of illness categories to be constituted not primarily as an ostensive relationship between signs and natural disease entities but as a 'syndrome' of symbols and experiences which typically 'run together' for the members of a society. Such analysis dirests our attention to the patterns of associations which provide meaning to elements of a medical lexicon and to the constitution of that meaning through the use of medical discourse to articulate distinctive configurations of social stress and to negotiate relief for the sufferer. This paper provides a critical discussion of medical semantics and develops a semantic network analysis of 'heart distress', a folk illness in Iran.
1. INT R O D UCTIO N
Human disease has provided anthropologists with an important domain for the investigation of cultural relativity, that is the meaningful shaping of 'natural' reality. Such studies are not of academic import alone. Our understanding of the way in which psychosocial and cultural factors affect the incidence , course , experience and outcome of disease is crucial for clinical medicine , both in the determination of what data is clinically relevant and where the therapeut;c intervention should occur. Our conception of disease and illness is. thus basic to cross-cultural studies of medicine and to medical practice (Kleinman, Eisenberg and Good 1976).
There have been a variety of recent efforts to 'de-entify' disease theory, to explore the view that diseases are not constituted as natural entities but as social and historical realities. A philosopher of medicine contends that a new 'ontological' basis for disease theory and medical practice is required , which can incorporate our recognition that a person's suffering is both a 'medical fact' and a 'socio-hfstorical fact' (Wartofsky 1975). Foucault's critical studies of medicine in Western history pose sharply the question of whether diseases are artifacts of historically-specific modes of treatment and theoretical constructs (Foucault 1965, 1973). On the other hand a variety of studies have assumed the view that disease is a dyna mic product of a person's relationship to his social and cultural environment : disease may be a response to social stresses or life events (e.g., Heisel et al. 1973) and is shaped in part by the nature of the cultural label which is applied to a person's condition (e.g., Waxler 1974). Efforts to apply such a
Culture, Medicine and Psychiatry I (1977) 25-58. All Rights Reserved. Copyright © 1977 by D. Reidel Publishing Company, Dordrecht-Holland.
26 B YRON J. GOOD
perspective clinically have found it necessary to reformulate disease theory in terms of 'open systems models' (Minuchin et al. 1975). Notwithstanding these constructive efforts, the 'medical model', which conceives diseases as natural entities that are reducible to physiological terms and are essentially free of cultural context, continues to have great force. Ironically, this perspective is assumed by a great deal of recent cross-cultural research. Ethnoscientific studies have conceived comparative analysis as the examination of the way diseases are mapped onto culturally constructed classificatory schema ta. It is the contention of this paper that such studies share with the medical model of disease certain basic (often unrecognized) assumptions about the relationship of language to medicine and about the nature of 'medical semantics' - the theory of how the meaning of medical language is constituted. These assumptions present obstacles to our understanding of the role of psychosocial and cultural factors in disease and therefore to an adequate cross-cultu ral research strategy.
The link between medicine and empiricist theories of language is a very old
one in Western philosophy. Givner (1962) argues that Locke's theory of language was modeled on the medical experiments of his friend Sydenham. Locke believed the two primary functions of language to be designation and classification (Givner 1962:346). This view predominates in ethnoscience. Meaning, it is held, is constituted as the relationship between classificatory categories and the diseases which they designate. Categories are defined by distinctive features which provide their boundaries. Such a theory of meaning is closely modeled on one mode of medical activity -diagnosis. Diagnosis is viewed as the linking of a patient's condition to a disease category through the interpretation of symptoms as distinctive features (e.g., Frake 1961). My criticism of this perspective is not that diagnosis is an unimportant mode of medical activity. Medical diagnosis, however, is an unsatisfactory model for the construction of new theories of disease, particularly when such theories are intended to redefine what data is relevant to diagnosis. And the ethnocentricity in the assumption in cross-cultural research that diagnosis is simply 'based on' physical symptomatology is exposed by, for example, Turner's analysis of Ndembu divination as the diagnosis of pathology in a patient's social field ( l 97 5). It is my argument , then, that we need not simply new theories of disease, but a new understanding of the relationship be tween medical language and disease. We need to develop a theory of medical language that does not reify the conception of disease and reduce medical semantics to the ostensive or naming function of language. Such a theory should direct cross-cultural resea rch away from simply examining how societies map classificatory categories onto disease to an analysis of the ma nner in which illness and disease are deeply integrated into the
structure of a society.
It will be proposed here that we use an analysis of 'semantic networks' to
understand the meaning of medical language as it is used in various communi cative contexts. The meaning of a disease category cannot be understood simply as a set of defining symptoms. It is rather a 'syndrome' of typical experiences, a set of words, experiences, and feelings which typically 'run together' for the members of a society. Such a syndrome is not merely a reflection of symptoms linked with each other in natural reality, but a set of experiences associated through networks of meaning and social interaction in a society. This conception of medical semantics directs our attention to the use of medical discourse to articulate the experience of distinctive patterns of social stress, to the use of illness language to negotiate relief for the sufferer, and thus to the constitution of the meaning of medical language in its use in a variety of communicative contexts.
In this paper I will analyze 'heart distress', one category of illness in Iran, in terms of its semantic network. This analysis will be used as the basis for suggestions for further research. The data for this paper was gathered during two years of field research in Maragheh, a Turki-speaking town in the province of
East Azerbaijan in northwest Iran.2