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VVVVVVVVVVV 1 Introduction Chronicity and the Experience of Illness LENOR E MANDERSON AND CAROLYN SMITH-MOR R IS In the past century, the world has witnessed dramatic epidemiological change. For reasons that we explore in this volume, the relative weight of infectious disease and injury on mortality and morbidity has declined, and instead, in the poorest and the wealthiest of nations, extended, often lifelong medical conditions predominate. These conditions neither develop nor continue in a vacuum, but are profoundly shaped by persistent injustice, inequality, poverty, and physical expressions of structural violence. These are all chronic problems; they interact with, contribute to, and shape the experiences of living with chronic health problems. These health problems include both infectious and noncommunicable diseases. Our intent in this book is to draw on the idea of chronicity to heighten sensitivity to the structural factors that create, maintain, and produce fluidity and flux in these disease patterns, their management, and outcomes in the twenty-first century. As we will elaborate here, anthropologists have exposed the structural factors behind everyday suffering for some decades, but we have been slow to theorize the relationship between social forces and epidemiology, let alone our own discourses of illness. Certain ideological assumptions remain invisible to us, and therefore influential in conversations that would otherwise be more vigilant of structural violence around the globe. The nomenclature that categorizes some illness categories as chronic is one such assumption. Our task has been to challenge a single, hegemonic conceptualization, to illustrate its role in supporting existing power structures behind global health paradigms, and to reaffirm the habitus of illness as a segregated, individual, and stigmaproducing event. Forty-seven percent of global morbidity is now attributable to what are called chronic conditions. The use of a temporal marker—the chronic or longterm aspect of disease—has largely gone unquestioned until now, at a time when some previously acute and infectious diseases can be survived long term, and 2 LENORE MANDERSON AND CAROLYN SMITH-MORRIS when medical technologies allow a symptom-free experience of “permanent” medical diagnoses. The old dichotomies—acute and infectious on one side, noncommunicable and chronic on the other—no longer hold, although neither medical anthropologists nor other health social scientists have done much to destabilize this chronic–acute typology or the representations and organization of diseases that are its fallout. Instead, medical scientists, clinicians, policy makers , patients, and consumers struggle to accommodate new technologies, interventions , and pharmaceuticals that potentially disrupt the paths and everyday impact of ill-health and disease. At the same time, they must interpret the meaning of a given diagnosis, in terms of cure and control, recovery and remission , in the economic and technological context of their own environment. In the past fifty years, technical, demographic, and epidemiological changes globally have placed new demands on health care and medical services, financing and insurance, social and economic life. International agencies, communitybased organizations, popular presses, and departments of health in both poor and rich resource settings have consistently played on this theme of change, its linearity, and its inevitable trajectory. As an example, Geoffrey Cannon from the World Health Policy Forum drew attention to the intersectoral and global nature of epidemic chronic diseases, and called for policies and programs involving “not only public health, but also finance, agriculture, manufacture, employment , development, trade, transportation, and education” (Cannon 2001: 1; 1992; Murray and Lopez 1996; World Health Organization [WHO] 1999). The WHO has also called for global action to prevent chronic disease and avert “millions of people dying prematurely and suffering needlessly from heart disease, stroke, cancer and diabetes” (WHO 2005b, 2005a). And in November 2007, the director general of WHO, Dr. Margaret Chan, in a speech to the directors of WHO country offices, reiterated the need to address the rise of chronic diseases, because they “now impose their greatest burden on low- and middle-income countries. Many chronic diseases require lifelong care, vastly increasing the burden on health systems. These diseases also increase costs—for households, health systems, and government budgets” (M. Chan 2007b). The urgency of these statements echo the views of many academics, writing from and about diverse settings, in editorials, monographs, and research articles, of the health of indigenous, immigrant, urban, and rural communities, and of the escalation of contributory factors associated with the increased incidence and treatment costs of chronic diseases (Anderson and Chu 2007; Horton 2005; Hoy et al. 2007). This global rhetoric takes the definition of chronic as...

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