White (2006: 142), “being sick is [thought to be] a biochemical process that is natural and not anything to do with our social life.” This view perseveres, White notes, despite the fact that it now applies to only a very limited range of medical conditions.
The persistence of the biomedical model is undoubtedly due to its great success in treating infectious diseases. Research in microbiology, biochemistry, and related fields resulted in the discovery and development of a large variety of drugs and drug-based techniques for effectively treating many diseases. This approach became medicine’s primary method for dealing with many of the problems it is called upon to treat, as its thinking became dominated by the use of drugs as “magic bullets or projectiles” that can be shot into the body to cure or control afflictions. As British historian Roy Porter (1997: 595) once explained: “Basic research, clinical science and technology working with one another have characterized the cutting edge of modern medicine. Progress has been made. For almost all diseases something can be done; some can be prevented or fully cured.” Also improvements in living conditions, especially diet, housing, public sanitation, and personal hygiene, were important in helping eliminate much of the threat from infectious diseases. Epidemiologist Thomas McKeown (1988) found these measures more effective than medical interventions on mortality from water and food-borne illnesses in the second half of the nineteenth century.
However, as a challenge to the biomedical model, McKeown’s thesis is considered rather tame since a rise in living standards – as would be expected – naturally improves health and reduces mortality. Moreover, McKeown has been criticized for his focus on the individual when an analysis of various social structural factors, such as changes in health policies and reforms, would have been insightful (Nettleton 2020). Nevertheless, general improvement in living standards and work conditions combined with health policies and the biomedical approach to make significant inroads in curbing infectious disease. By the late 1960s, with the near eradication of polio and smallpox, infectious diseases had been largely curtailed in most regions of the world. The limiting of infectious diseases led to longer life spans, with chronic illnesses, which by definition are long-term and incurable, replacing infectious diseases as the major threats to health. This epidemiological transition occurred initially in industrialized nations and then spread throughout the world. It is characterized by the movement of chronic diseases such as cancer, heart disease, and stroke to the forefront of health afflictions as the leading causes of death. As Porter (1997) observed, cancer was familiar to physicians as far back as ancient Greece and Rome, but it has become exceedingly more prevalent as life spans increase.
Epidemiologic transition theory offers an explanation of this progression as it finds that some diseases are more prevalent in particular historical periods than others (Omran 1971). The theory divides the major causes of mortality into three distinct stages or “ages”: (1) the “Age of Pestilence and Famine” in which infectious and parasitic diseases are the major causes of death from the earliest times until the 1800s; (2) the “Age of Receding Epidemics,” a transitional stage during which infectious and parasitic diseases are brought under control by improved hygiene, sanitation, nutrition, public health measures, higher standards of living, and medical advances featuring mass immunizations, antibiotics, more advanced surgical techniques, and other innovations from the early 1800s to about 1960; and (3) the “Age of Degenerative and Man-Made Diseases” in which chronic diseases, such as cardiovascular disease and cancer, emerge as the dominant causes of mortality beginning around 1960, thereby making infectious diseases even less important. In the third stage, social factors become more prominent because of their connections to heart disease (Cockerham, Hamby, and Oates 2017c) and cancer (Hiatt and Breen 2008) by way of health lifestyles, stress, and environmental hazards.
This theory seemed a representative summary of epidemiological trends until the 1970s and 1980s when there was a surprisingly rapid decline in deaths from cardiovascular disease, followed by the arrival of new infectious diseases in the late 1990s and early 2000s – such as West Nile, SARS, Ebola, and Zika (Armelagos and Harper 2016). These changes led some to propose modifications in the theory. This included adding newly emerging infectious diseases to the third stage, since these diseases had made an unexpected and deadly appearance, and creating a new fourth stage, such as a “Hybristic [or Mixed] Age” in which individual behaviors and lifestyles are added to heart disease and cancer as another major cause of mortality (Rodgers and Hackenberg 1987), an “Age of Delayed Degenerative Diseases” in which chronic diseases like heart disease and cancer do not result in death until increasingly older ages (Olshansky and Ault 1986), or the “Age of the Cardiovascular Revolution” during which improvements in medicine pertaining to heart disease continue to reduce mortality and improve life expectancy (Meslé and Vallin 2006).
In a yet to be decided Stage Four, social factors are especially relevant regardless of whether it is a case of “Hybristic (Mixed) Causes” featuring risky behaviors (i.e., lifestyles) as a major cause of death, “delayed degenerative diseases” in which the biological effects of aging or the physical “weathering” of the body caused by social stress and the consequences of unhealthy lifestyle practices are postponed as life expectancy increases, or the “cardiovascular revolution” where health lifestyles are again paramount in mortality outcomes because of their close association with heart disease. In this new fourth stage, smoking, obesity, and unhealthy behavior, along with the addition of climate change, will likely be important, along with newly emerging infectious diseases like Zika and especially the coronavirus (COVID-19). The addition of newly emerging infectious diseases suggests a partial return to Stage 1 and the “Age of Pestilence,” further signaling a much needed revision of epidemiologic transition theory. What is obvious is that this current stage of epidemiological transition needs to take cognizance of the fact that good or bad behavioral practices cause good or bad health.
As for heart disease, Porter (1997: 585) notes the comments of a leading British medical doctor who observed in 1892 that cardiac deaths were “relatively rare.” However, within a few decades, heart disease had become the leading cause of death throughout Western society as life expectancy increased. New diagnostic techniques, drugs, and surgical procedures including heart transplants, by-pass surgery, and angioplasty were developed in response. Porter also finds that greater public awareness of risk factors like smoking, poor diet, obesity, and lack of exercise along with lifestyle changes made a fundamental contribution to improving cardiovascular health.
The transition to chronic diseases meant medicine was called upon to confront the health problems of the “whole” person, which extend well beyond singular causes of disease such as a virus that fit the biomedical model. As Porter pointed out, even though the twentieth century witnessed the most intense concentration of attention and resources ever on chronic diseases, they have nevertheless persisted. “It can be argued,” states Porter (1997: 594), “that one reason why there has been relatively little success in eradicating them is because the strategies which earlier worked so well for tackling acute infectious diseases have proved inappropriate for dealing with chronic and degenerative conditions, and it has been hard to discard the successful ‘microbe hunters’ formula.”
Consequently, modern medicine is increasingly required to develop insights into the social behaviors characteristic of the people it treats. According to Porter, it is not only radical thinkers who appeal for a new “wholism” in medical practice that takes social factors into consideration, but many of the most respected figures in medicine were insistent that treating the body as a mechanical model would not produce true health. Porter (1997: 634) states:
Disease became conceptualized after 1900 as a social no less than a biological phenomenon, to be understood statistically, sociologically, and psychologically – even politically. Medicine’s gaze had to incorporate wider questions of income, lifestyle, diet, habit, employment, education, and family structure – in short, the entire psychosocial economy. Only thus could medicine meet the challenge of mass society, supplanting laboratory medicine preoccupied with minute investigation of lesions but indifferent as to how they got there.
Contemporary physicians now treat many health maladies that are aptly described as “problems of living,” dysfunctions
