Book Review

Evolution of Sickness and Healing

N Engl J Med 1997; 337:796-797September 11, 1997

Article

Evolution of Sickness and Healing
By Horacio Fábrega, Jr. 364 pp., illustrated. Berkeley, University of California Press, 1997. $45. ISBN: 0-520-20609-6

Although 19th-century evolutionary philosophers, notably Herbert Spencer (1820 to 1903), made large claims for the biologic basis of human beliefs and practices, serious discussion of a biologic or genetic basis for social customs and structures went into a prolonged eclipse with the rise of the Nazis. In 1975, Edward O. Wilson, the noted Harvard entomologist, revived the field when he gave it a new name — sociobiology — and intellectual respectability with his influential book, Sociobiology: The New Synthesis (Cambridge, Mass.: Belknap Press of Harvard University Press). Heretofore, sociobiologists have had relatively little to say to orthodox medicine. Dr. Horacio Fábrega, Jr., seeks to remedy this reticence by applying sociobiologic theory to sickness and healing behavior from the beginnings of the human presence on Earth to the present.

Fábrega's sweep is grand, for he starts with specific helping behavior in higher primates and ends with physician–patient interactions in health maintenance organizations. Laying out his key theoretical concepts in chapters 2 and 8, Fábrega argues for an “innate,” “wired-in” biologic trait for sickness and healing that “is constructed by natural selection and reinforced by cultural learning.” Sickness and healing, in turn, is made up of “medical memes,” including “sick memes” and “heal memes,” which Fábrega defines as “units of cultural information that members of a community or population develop, store, and use for purposes of combating the effects of disease and injury.” The author directs readers to think of these “memes” as “medical genes” in order “to better visualize and make epistemological use of the complex, biocultural nature of the adaptation that lies at the root of medicine.”

According to Fábrega, evolutionary evidence of this idea rests on empirical studies of primate behavior, and his most frequently cited references are Jane Goodall's observations of the specific helping behavior of wild chimpanzees. Fábrega also cites studies by other animal anthropologists and physical anthropologists who study the remains of human life from the Pleistocene era forward. In other sections Fábrega characterizes the major literate traditions of medical thought (Greek, Chinese, Arabic, and ayurvedic) as well as nonliterate shamanic practices so as to bring them into the fold of his evolutionary theory.

Numerous objections may be mounted against Fábrega's arguments and their exposition, but I will mention only two. Darwinian natural selection speaks only to the events in an organism's life that precede reproduction; genes that express themselves after the reproductive period exert minimal selective pressure. Consequently, evolution is indifferent on the subject of aging. Indeed, the average animal in the wild, including humans living as hunter–gatherers, does not live very long. Furthermore, according to some of the references the author cites, neither well chimpanzees nor hunter–gatherer humans lavish much attention on the seriously ill or injured.

The average life span in industrialized countries has increased from 40 or 45 years in 1900 to more than 70 years today. Chronic disease accounts for most morbidity and mortality. Currently, we spend most of our health care resources on interventions with the elderly. But if aging is an artifact of civilization, and not due to natural selection, how relevant are the claims of sociobiologists concerning present health care arrangements? In sum, even in its own terms, the explanatory power of Fábrega's theory is weak.

Fábrega's exposition begins with extensive citations of work in other fields, after which he expends pages developing his own theory with little reference to authors other than himself. But the works cited do not necessarily support Fábrega's use of them. Often, in closing a section, Fábrega uses the works of other sociobiologists as confirmation. Aside from the questionable use of some sources, one wants to ask, is this expository practice characteristic of science — Fábrega's claim — or scientism? In common with other sociobiologists, Fábrega subsumes history and other forms of social analysis under the category of “evolutionary biology,” a rhetorical move that permits him to collapse divisions between nature and culture as well as evade substantive engagement with analytic perspectives from other disciplines.

Robert L. Martensen, M.D., Ph.D.
University of Kansas School of Medicine, Kansas City, KS 66160-7311