Banishing Risk: Or the More Things Change the More They Remain the Same

BANISHING RISK: OR THE MORE THINGS CHANGE THE MORE THEY REMAIN THE SAME CHARLES E. ROSENBERG* We honor randomness in the abstract, but seek to manage it in practice , to constrain misfortune in reassuring frameworks of meaning [I]. We want health to make predictive sense, to be based on coherent relationships between behavior and its consequences. Notions about the causation and nature of disease are and have been throughout history inextricably bound up with meaning and identity. Blame, guilt, and anxiety can be harnessed in powerful conjunction—as can the presumed interaction between body and mind. We are what we have done or neglected to do. These ideas have been articulated countless times and in a variety of forms, from classical antiquity to the present. Throughout the history of Western medical thought, chronic sickness—and predisposition to acute and epidemic ills—was generally understood to be a cumulative product of the longtime interaction between a biologically unique individual and a particular environment. As the body moved through time, it required food and water, sleep and exercise; one was always becoming , thus always at risk. Every circumstance of life and each day-to-day decision were physiologically meaningful. Habits of living once established could lead cumulatively—but with ultimate inexorability—to sickness and death,just as they could, if properly regulated, maintain health well into old age. It must be recalled that until the mid-19th century the concept of This paper was prepared for a conference on "Morality, Health and History," sponsored by the John D. and Catherine T. MacArthur Foundation network on the Determinants and Consequences of Health-Promoting and Health-Damaging Behavior, Santa Fe, N.M., June 21-23, 1992. I am grateful for the criticism of conference participants and, in addition, I wish to thank Barbara Bates, Chris Feudtner, Renee Fox, Gerald N. Grob, Steven J. Kunitz, and Irvine Loudon, who were kind enough to read and comment on this paper. *Department of History and Sociology of Science, University of Pennsylvania, 3440 Market Street, Suite 500, Philadelphia, Pennsylvania 19104.© 1995 by The University of Chicago. All rights reserved. 0031-5982/95/3804-0927$01.00 28 Charles E. Rosenberg ¦ Banishing Risk specific disease entities was not understood in the modern sense; a cold could shade into tuberculosis, a bruise into cancer, disorderly eating habits into gout or diabetes. In this sense, a bad habit indulged in over time was, literally, the first stage in a disease process. Lack of disease specificity implied an elusive yet omnipresent nemesis, but one that could be understood, anticipated, and averted. Logically enough, 17thand 18th-century guides to health and longevity emphasized the need to control all those aspects of life a prudent man or woman could control : diet, exercise, sleep, the evacuations and emotions. In the terminology of the day, and following a tradition that could be traced back to Galen, such factors were termed the "non-naturals," as opposed to the "naturals," those innate factors which might also lead to disease. "By the term 'non-naturals' were understood all those things which are essential to life, but which neither enter into the composition of the animal oeconomy, nor form part ofthe living body. These comprehend air, foods and drinks, motion and rest, sleep and wakefulness, secretions, excretions, and retentions, mental emotions, clothing, bathing, &c." [1, pp. vii—viii]. It is obvious that such concern with day-to-day routine provided an occasion for enforcing a society's behavioral norms; there could be no practical distinction between the realms of morality, meaning, and mechanism. The symptoms of moral sickness—sexual promiscuity, gluttony , sloth, uncontrolled emotional excess—inevitably undermined physical health. Much of this age-old emphasis on regimen will seem enlightened and even prescient to health-conscious late twentieth-century readers. But too much has intervened between the late 18th century and the present; it is no longer possible to share the assumptions of traditional medicine —even if particular elements in that configuration of ideas seem familiar. I would like to emphasize four themes fundamental to this traditional way of understanding health and disease, themes configured so as to constitute a way of thinking about the body antithetical to certain dominant trends in...