Book Review

Illness and Culture in the Postmodern Age

N Engl J Med 1999; 340:396February 4, 1999

Article

Illness and Culture in the Postmodern Age
By David B. Morris. 345 pp. Berkeley, University of California Press, 1998. $27.50. ISBN: 0-520-20869-2

Our minds live in particular bodies, of course — hence the psychologically shaping influence of biology, as sickness soon enough reminds us. The onset of a disease gives us plenty of opportunity for thought, and in no time, rather often, we are a source of worry for some and of shame for others, depending on what ails us and where we happen to live. In a sense, then, genes, viruses, or bacteria, for all their decisive say in who gets what disease, have only so much of a hold on things. The families to which we belong and the neighborhoods or nations in which we live exert their influence on us not only as patients but also as persons who learn to accommodate ourselves to certain cultural (and religious) norms — the values, ideals, practices, and preferences that inform the world we call our own.

None of the foregoing is all that surprising; it is the stuff of common sense. Even so, this book by an essayist who has observed modern medical life deserves respectful attention. David Morris has already (in The Culture of Pain; Berkeley: University of California Press, 1991) tried to link a universal aspect of medicine to certain historical and cultural circumstances through literature and art, as he does here again; indeed, this book's title announces his intellectual intent, and his discussion of pain helps him approach his essential subject matter — the way in which a person's place in life and his or her beliefs, hopes, and worries all come to bear on what pain does, how it is interpreted and handled, and what the consequences are.

Pain “is more than a medical issue,” he insists, “and more than a matter of nerves and transmitters.” Here, and throughout this book, Morris takes on what he terms, with no admiration, “the mechanistic biomedical model.”

Morris calls on a most persuasive and prominent witness, the novelist Reynolds Price, whose struggle with a tumor of the spinal cord prompted not only a search for medical care but also a deeply felt search within himself, an intense scrutiny of his life, its purpose, and its meaning. To Morris, Price is a hero, his look inward and outward a kind of transcendence. By implication, Price's doctors, and many others, fell far short of such an achievement, wedded as they were to an insistence on understanding this or that illness physiologically or anatomically, with little or no concomitant interest in trying to know the afflicted person and trying to figure out what has happened to him or her in mind, in spirit, in manner of living and working, and in outlook on life.

Not that most clinicians need to be reminded that a changed mental state is an aspect of clinical duress. Many diseases certainly prompt melancholy stories that started after cells began to run amok or viruses became destructive, even lethal, invaders of a body. We are, of course, asked to keep in mind black-lung disease and malaria, illnesses that make the book's point, that occur as a result of a certain kind of lifestyle: work done here, travel undertaken there — culture as a determinant of illness and of the character of illness, its manner of expression. A chapter titled “Neurobiology and the Obscene” delves into that subject: “In coprolalia, we confront not just a neurological disorder such as uncontrolled twitching but a mobilization of the complex cultural resource called obscenity.” So it went in the 19th century for workers who got mercury poisoning while making hats. They were plagued by tremors and twitches and were viewed as odd and crazy because of their speech. Hence the phrase “mad as a hatter” — a vernacular and intuitive expression that exemplifies the author's point.

In our time, other troubles come to some of us, and they, too, tell of us — illness as telltale evidence of life in society and of values that prompt behavior that in the long run becomes exceedingly hurtful to a body, to health. Morris cites a historian who reminds us that “an epidemic such as AIDS could not have occurred before the mingling of races, before the liberalization of sexual mores, and, above all, before medicine had controlled serious infectious diseases and introduced both intravenous injections and blood transfusions.” Nor is anorexia nervosa without a decided connection to our modern era — what the author calls “the biology of self-starvation.” It is a consequence of culture (advertising on television and in magazines) come to bear on human desire and, literally, appetite: it is better to abstain forthrightly than to appear “heavy,” even if one risks dying.

There are fine moments in this book — when, for instance, Morris calls on the poets Wallace Stevens and Dante or when he evokes our gadget-filled world (computers, the Internet, television) and indicates our susceptibility to it as well as to germs. Even heart disease and cancer can be prompted by that world and by the activities and habits of consumption it urges on us. It is well for us doctors to be aware of these effects, but at moments, alas, we learn that our failures of clarity or vision are shared by others. “Every utterance constitutes a miniature text,” Morris tells us, “and Jacques Derrida makes the crucial point when he writes that `there is no genreless text.'” Other such murky theoretical flourishes from French writers (Foucault appears frequently) supply ironic evidence that culture can shape not only the way we act and feel while we are sick, but also how we think and, worst of all, how we talk and write.

Robert Coles, M.D.
Harvard University Health Services, Cambridge, MA 02138