Theoretical approaches to understanding a disease notion: global recommendations.
By Monika Rau, Trainee Lecturer in Health, LSST Elephant and Castle
Understanding diseases is a complex endeavour that requires considering multiple theoretical approaches. Each approach offers unique insights into how diseases develop, progress and can be treated. Having a psychological background, a disease notion requires a holistic approach and, thus, both theoretical and practical perspectives. This article aims to explore various theoretical frameworks, including reductionist, holistic, prototype resemblance, naturalistic, and evolutionary mismatch theories, to provide a comprehensive understanding of diseases. Additionally, global recommendations will be discussed to respond to the challenges posed by globalisation and the need for more inclusive health strategies in an ever-changing world.
Theoretical approaches.
Reductionist viewpoint.
The reductionist view defines disease as a bodily or mental deviation, focusing on malfunctions at the cellular, genetic, or molecular level (Van Regenmortel, 2014; Hofmann, 1997). Scientists, Watson and Crick in 1953 were the first to investigate DNA elements to understand molecular underlying mechanisms (Hernandez, 2019). For instance, cancer research. That is a very complex and fatal disease unit. Looking at genetic mutations in cancer cells or the dysregulation of signalling pathways allows us to understand its complexity. It is good to be as narrow as possible during studies, as it provides insight into how the body functions and gives an opportunity to set effective treatments.
While it provides valuable insights into body functions and treatment options, critics argue it oversimplifies complex diseases by neglecting broader contexts, the reductionist may overlook interactions between genetic, environmental, and lifestyle factors, limiting a holistic understanding of health (Rivas et al., 2017, Rocca and Anjum, 2020). A disease is not just a body malfunction. The body interacts with the surrounding environment, such as urban pollution or toxic working conditions. Lifestyle factors contribute to the disease’s development or progression too. Fardet and Rock (2014) model based on nutrition highlights that a holistic approach is related to a reductionist perspective and vice versa. Being focused on individual components limits our understanding of the holistic nature of health.
Holistic approach
Hofmann (1997) considers interactions between all ontological levels in the human being. Such an integrative perspective on biological aspects leads to the understanding and development of preventive and actionable models. Michaelson et al. (2016) emphasised the value of the holistic approach in considering health influencing factors. This approach addresses not only physical symptoms but also emotional, mental, and social aspects. For example, chronic pain management would involve pharmacology alongside alternative therapies such as acupuncture, physical therapy, stress reduction, and lifestyle changes. Moreover, lifestyle factors such as diet, exercise, and social aspects would be included in the holistic management of pain. There are different underlying causes of the pain, which would require a relevant approach in each situation. The holistic approach recognises that different underlying causes of pain require individualised treatment strategies.
Prototype resemblance theory.
That conceptual perspective suggests that understanding a disease is based on how closely it resembles a mental prototype of that disease. When people think about the disease, they compare it to a prototype that includes the most typical or representative features. According to Sadegh-Zadeh (2008), that approach provides new perspectives on resolving problems associated with the concept of disease but there is not enough evidence to explain it exactly. For example, when thinking about the flu, symptoms like fever, cough, and body aches are typical features of the prototype. If your experience closely matches this prototype, you are likely to identify it as the flu. However, Hofmann (2017) argued that the prototype resemblance theory is not emphatically supported. He found that health professionals do not have a prototype concept of disease. Ipso facto, there is unlikely to be a prototype concept of disease in general. Consequently, it should not be based on prototypes.
(Note: Nosology refers to the science of defining and classifying diseases. Also, it explores whether diseases could be defined in a better way than they are now (Livingston-Banks, 2018).
Naturalistic approach.
Naturalistic approach views diseases as entities that exist independently in the natural world, with specific causes, symptoms, and natural histories that could be observed, studied, and classified based on their biological and psychological characteristics. This includes infectious agents, genetic, environmental, or physiological processes. The approach defines diseases based on the biological functions and disfunctions of the body. However, Chin-Yee and Upshur (2017) argue that the distinctions between function and disfunction is not straightforward as there are ongoing debates about how to define these attributes in organisms. This has led to criticism of the naturalistic theory, and discussions about improving disease definitions (Chin-Yee and Upshur, 2017; Veit, 2021). Despite these challenges, the naturalistic view highlights the importance of understanding the natural causes and manifestations of diseases to effectively diagnose, treat, and prevent them.
Evolutionary mismatch theory.
The evolutionary mismatch theory suggests that diseases result from disconnections between the environment in which the individual’s body grew up and the modern environment. For instance, traits or behaviours that were advantageous for survival and reproductive purposes in the past become maladaptive decades later or in current settings leading to an increased susceptibility to various diseases. A more specific example would be related to rapid cultural and lifestyle changes. For instance, factors such as diet, physical activity patterns, and toxin exposure can contribute to a mismatch, that increases the prevalence of obesity, cardiac diseases, and diabetes (Lea et al., 2023). This concept believes that changes in human culture and lifestyle have created a disconnection between our ancestral traits and the modern environment, contributing to the emergence of various diseases and conditions (Manus, 2018). Scalera, Gallina, Gasparetto, and Seriani (2017) demonstrated it below on a body weight example addressing the obesity problem due to common access to sugar-rich food triggering hedonic pleasure.
So, what…? What could be learned from that?
Reflecting on various approaches to explaining disease phenomena indicates their complexity. Each approach discussed above provides relevant insights. They highlight the importance of considering the “set settings” and environmental factors that interact with the body. There is no simple way to understand disease as the environment is as complex as the human body and they evolve together over time. While individual-level approaches are crucial for understanding the cellular mechanisms, awareness of environmental interactions, advantages, disadvantages, and consequences is also valuable. Concepts focused on the environmental context and general body level are crucial for interpreting and applying knowledge to the broader population. An integrated perspective is necessary for designing health services design, policies, and legislation.
However, history is full of cases where individuals were suffering due to lack of access to treatment, late diagnosis, or abuse of authority power. Global health initiatives, while aiming to improve outcomes, can also have unintended consequences. For example, van de Ruit (2019) study on the Community Health Worker (CHW) program in South Africa found that structural and local factors contributed to challenges like workers having multiple jobs, unregulated freelance work, and poor patient outcomes due to disorganised care. These consequences undermined the goals of the national health system and threatened the sustainability of the CHW program. This illustrated how complex interactions between global initiatives and local dynamics can lead to unintended outcomes that must be considered (van de Ruit, 2019).
Recommendations
The top priority should be for authorities to respect individuals and apologise for any unintended harm caused. Addiss and Amon’s (2019) study emphasises that little is known regarding apology and reparation practices and authorities often prioritise political correctness ambitions and economic desires over individual community members. Another suggestion proposed by Addiss and Amon (2019) is to develop an ethical, human rights, and legal framework to address unintentional harm in appropriate ways by applying relevant agreements, declarations and instruments from the United Nations.
Additionally, it is proposed to systematically examine the unintended consequences of these global health initiatives, using social theoretical approaches and frameworks to assess harmful cases, collect data and devise solutions (Turcotte-Tremblay, Gali Gali, and Ridde, 2021). These recommendations promote a more inclusive approach, acknowledging that nothing is perfect and that there are always two sides to consider. The focus should be on preventing harm, designing alternative options, and adjusting legislation to promote inclusion rather than practice punishment.
In summary, concepts focused on the environmental context and general body-environment interactions are valuable in understanding and addressing diseases. A holistic, multifaceted approach that combines different theoretical perspectives is most likely to yield a comprehensive understanding of diseases and inform effective prevention and treatment strategies. Each theoretical approach presented in this article provides relevant insights into the complexity of the disease phenomenon. While individual approaches are essential for understanding cellular mechanisms, considering interactions with the environment, their advantages, disadvantages, and consequences are also valuable. A holistic and multidimensional theoretical framework, combining these different perspectives, seems best suited to enable a comprehensive understanding of diseases and to guide effective prevention and treatment strategies. An integrated approach, considering both individual and environmental factors, is necessary to grasp the complexity of the disease phenomenon in an ever-changing world.
References.
Addiss, D. G., and Amon, J. J. (2019). Apologies and unintended harm to global health. Health and Human Rights, 21(1), p. 19.
Bowman, C. R., Iwashita, T., and Zeithamova, D. (2020). Tracking prototype and exemplar representations in the brain across learning, elife, 9, e59360.
Chin-Yee, B., and Upshur, R.E. (2017). Re-evaluating concepts of biological function in clinical medicine: towards a new naturalistic theory of disease. Theoretical Medicine and Bioethics, 38, pp. 245-264.
Fardet, A., and Rock, E. (2014). Toward a new philosophy of preventive nutrition: from a reductionist to a holistic paradigm to improve nutritional recommendations. Advances in nutrition 5(4), 430-446.
Racine, V., 2014. “Molecular Structure of Nucleic Acids: A Structure for Deoxyribose Nucleic Acid” (1953), by James Watson and Francis Crick. [online] Embryo Project Encyclopedia. Available at: https://embryo.asu.edu/pages/molecular-structure-nucleic-acids-structure-deoxyribose-nucleic-acid-1953-james-watson-and [Accessed 10 July 2024].
Hofmann, B. (1997). Holistic health and specific diseases. Tidsskrift for den Norske Laegeforening: Tidsskrift for Practical Medicine, Ny Raekke, 117(17), pp. 2478–2480. Hofmann, B. (2017). Do health professionals have a prototype concept of disease? The answer is no. Philosophy, Ethics, and Humanities in Medicine, 12, pp. 1–7.
Lea, A. J., Clark, A. G., Dahl, A. W., Devinsky, O., Garcia, A. R., Golden, C. D., Kamau, J., Kraft, T. S., Lim, Y. A., Martins, D. J., and Mogoi, D. (2023). Applying an evolutionary mismatch framework to understand disease susceptibility. PLoS biology, 21(9), p. e3002311
Livingstone‐Banks, J. (2018). The case for a meta-nosological investigation of pragmatic disease definition and classification. Journal of evaluation in clinical practice, 24(5), pp. 1013–1018.
Manus, M. B. (2018). Evolutionary mismatch. Evolution, medicine, and public health, 2018(1), pp. 190–191.
Michaelson, V., Pickett, W., King, N., and Davison, C. (2016). Testing the theory of holism: A study of family systems and adolescent health. Preventive medicine reports, 4, pp. 313–319
Rivas, A. L., Leitner, G., Jankowski, M. D., Hoogesteijn, A. L., Iandiorio, M. J., Chatzipanagiotou, S., Ioannidis, A., Blum, S. E., Piccinini, R., Antoniades, A., Fazio, J. C., Apidianakis, Y., Fair, J. M., & Van Regenmortel, M. H. V. (2017). Nature and Consequences of Biological Reductionism for the Immunological Study of Infectious Diseases. Frontiers in immunology, 8, 612. https://doi.org/10.3389/fimmu.2017.00612
Rocca, E. and Anjum, R.L., 2020. Complexity, Reductionism and the Biomedical Model. In: R.L. Anjum, S. Copeland and E. Rocca, eds. Rethinking Causality, Complexity and Evidence for the Unique Patient. Cham: Springer. Available at: https://link.springer.com/chapter/10.1007/978-3-030-41239-5_5 [Accessed 10 July 2024].
Sadegh-Zadeh, K. (2008). The prototype resemblance theory of disease. Journal of Medicine and Philosophy, 33(2), pp. 106–139.
Scalera, L., Gallina, P., Gasparetto, A., & Seriani, S. (2017). Anti-hedonistic machines. International Journal of Mechanics and Control, 18(02), 9-16.
van de Ruit, C. (2019). Unintended consequences of community health worker programs in South Africa. Qualitative health research, 29(11), pp. 1535–1548 Veit, W. (2021). Biological normativity: a new hope for naturalism?. Medicine, Health Care, and Philosophy, 24(2), pp. 291-301.
Van Regenmortel M. H. (2004). Reductionism and complexity in molecular biology. Scientists now have the tools to unravel biological and overcome the limitations of reductionism. EMBO reports, 5(11), 1016–1020. https://doi.org/10.1038/sj.embor.7400284
Wakelin, D. (1996). Helminths: Pathogenesis and Defences. Baron S., editor. Medical Microbiology, 4th Edition. Galveston (TX): University of Texas Medical Branch at Galveston. Chapter 87. Available at: https://www.ncbi.nlm.nih.gov/books/NBK8191/