Nature or nurture?
While scientists seek to pin down the roles of nature and nurture in disease, historians at the University of Exeter are telling a less material story.
Attempts to unravel the relationship between genes, the environment and our health are revealing a very complicated picture: while the World Health Organization has been systematically cataloguing the environmental impact on health over the last decade, scientists have been uncovering the genetic determinants of more and more diseases.
At the Centre for Medical History at the University of Exeter, Professor Mark Jackson and colleagues are looking at the question from a historical angle. The team was recently awarded a five-year Wellcome Trust Strategic Award in the History of Medicine to investigate how the roles of nature and nurture in health and disease have been perceived at different times over the last 150 years. A cohesive group with a shared vision and many crossovers of research interests (see box), researchers at the Centre are focusing on three main areas of disease: respiratory diseases, mental deficiency and infanticide.
Of particular interest is the medical history of the surrounding south-west region. Devon and Cornwall are old mining counties, and workers suffered respiratory diseases related to conditions in the mines. Conversely, in the 19th century, when the railway was extended through to Torbay and Exmouth, the environment played a healing role. People travelled to Teignmouth, Torquay and Paignton to mend shattered 'nerves' or recover from tuberculosis in the cleansing, bracing sea air. The south-west therefore offers plenty of scope for studying perceptions of how environmental factors influenced disease and recovery. Moreover, the region has the added advantages (from a historian's point of view) of a rich medical archive, and opportunities to collect oral histories and first-hand accounts from local inhabitants.
Professor Jackson believes that integrating environmental history with the history of medicine, recently designated a priority area by the Wellcome Trust, will broaden out the field and add a new dimension to the complex, shifting historical picture of disease. However, he is keen to stress that history is not addressing the same questions as scientific endeavours. "As historians of medicine, we're not trying to find out whether it was nature or nurture that caused a disease," says Professor Jackson. "What we're interested in is why does society choose either explanation at any one point?"
On one level, the emergence of a disease, its symptoms, and attempts to cure it all constitute an apparently straightforward, material story. Yet, as Professor Jackson points out, on a different level a disease is not simply a biological event. It is also a subjective experience, shaped by the perceptions and responses of patients and doctors. "You hear people say a cold is caused by exposure to cold temperatures, or that watching television makes children obese. These statements aren't scientific facts, they're just beliefs, however deeply ingrained they might be in society. A disease is a social construction, as well as a biological phenomenon. That's the story we want to tell."
Differing perceptions of respiratory diseases and allergies at different times underline the importance of that most essential element of culture, language, in the emergence and shaping of a disease. Before 1819, when hay fever was first identified as a distinct disorder, it was unknown, yet after it was described, the number of cases rose steadily. "This creates a tension in the writing of history," notes Professor Jackson. "Can you have a disease before it is named?"
Diseases don't just get a name, they also acquire other cultural trappings - value, meaning, even a cultural personality. During the 19th century, for example, cultural and political explanations for hay fever correlated with the proliferation of the middle classes. Educated, cultured people were more sensitive, they developed 'nerves' and were hence more prone to asthma and hay fever. Thus hay fever was heralded as a mark of intellectual superiority of the cultured, educated classes. There was even a racial aspect: the English and Germans tended to be more prone to hay fever than other nationalities and were hence deemed superior in intellect and culture.
Such views of hay fever as innate - either to a person's class, race or personality - were at other times superseded by, or coexistent with, environmental explanations: by the 20th century, rising levels of hay fever were linked more to urbanization and changing agricultural practices. At any time, as Professor Jackson points out, the prevailing explanation - environment or heredity - reflected and supported particular political, social and cultural structures. The view of hay fever as a middle class disease, for example, may have had a subtle role to play in maintaining the status quo by underlining class distinctions.
Similar political and social factors informed perceptions of the roles of nature and nurture in mental health and infanticide. In Victorian England, it was common practice for the mothers of illegitimate children to hand their children, together with a fee, to baby farmers, at whose hands they then died. "Were these mothers inherently bad, uncaring, unstable mothers, or were their social and economic circumstances so harsh and constrained that they were driven to hand their children over to murderers?" asks Professor Jackson. "We're interested in how society explained the proliferation of infanticide - and why it chose that particular explanation."
Explanations at the time favoured nature over nurture. Unwed mothers were seen as innately immoral, and fears that children conceived in sin would inherit their parent's lack of moral character led to segregational policies in workhouses and orphanages. Here again, a number of political, pragmatic and social factors played their role in shaping this harsh view of 'fallen women'. When the 1834 New Poor Law laid responsibility for the care of illegitimate children solely in the hands of the mother, it absolved the father - and the government - of any responsibility. Such a view, upheld by law, had considerable financial benefits for local and national government, not to mention the fathers of illegitimate children, and may have helped to support a society that by and large believed in and operated on the basis of the superiority of men.
Despite being closer to the material reality of disease than law-making bodies and governments, clinicians likewise came under the influence of political, pragmatic, professional and financial considerations that shaped and sometimes distorted their response to a disease.
In the early part of the 20th century, at the Allergy Department at St Mary's Hospital, John Freeman and Leonard Noon developed a new form of treatment for hay fever and asthma. The treatment, called desensitization, involved inducing tolerance to pollen by injecting patients with increasing doses of pollen to force their immune systems to make antibodies to the toxin.
Desensitization ignored the growing body of evidence pointing to the role of immunological reactivity in hay fever, and was instead based on studies of bacterial inoculation against typhoid. There were commercial as well as pragmatic reasons for taking this approach: Freeman and Noon needed to produce commercial vaccines to subsidize their experimental and therapeutic work at St Mary's, and were supported financially by a US pharmaceutical company, Parke, Davis & Co., which marketed their pollen preparations as 'Pollaccine'.
Although it was developed with little regard for the physiological mechanisms of allergy, desensitization was an unqualified clinical success. Without any clear explanation of its mode of action, and despite concerns about efficacy and safety, it became the cornerstone of clinical allergy in the UK until the 1960s - as clear an illustration as any of how explanations and experience of a disease, and approaches to its treatment, are determined by factors that may have little to do with the disease itself.
"We're not trying to draw conclusions here, merely to draw out some of the issues," stresses Professor Jackson. "Historians don't have any closure: it's one of the critical challenges of writing history. We want to uncover some of the myriad factors at play when people form a particular view or explanation of a disease, and to show how everything is inter-related.
"I think it's also important to note that whichever explanation you choose - nature or nurture - will affect the action you take. Intuitively, I can't help feeling that if you take the biological, genetic approach you commit to socially problematic solutions, like sterilization, segregation, or discriminatory legislation and policies, whereas if you take the environmental approach you can address problems more constructively, perhaps improve housing and poverty. But as I say, that's an intuition, not a fact. What matters is to be alert to the factors that shape our perceptions of things and thus impact on what we decide to do about them." PB
The research team
• Professor Mark Jackson - the history of allergic diseases, mental deficiency, infanticide, and the role of humanities in medical education.
• Dr Jonathan Barry - medicine in provincial English towns in the early modern period, and religion and demonology 1600-1700.
• Dr Kate Fisher - birth control and medicine in the twentieth century, and changing sexual practices and behaviour within marriage.
• Dr Joseph Melling - occupational diseases, workplace pollution, legislation, and the history of insanity and psychiatric treatment.
• Dr Mark Bufton - medical treatments of silicosis, public policy and food science and nutrition.
• Dr Catherine Mills - a research fellow working on air pollution in post-war Britain.
• Dr Pamela Dale - working on mental deficiency and health visiting in the 20th century
• Cath Quinn - researching puerperal insanity and the history of childbirth.
Other activities
• The Centre offers a number of undergraduate and postgraduate modules in the history of medicine to students at the university and to medical students at the nearby Peninsula Medical School.
• Since 2001, the Centre has run an MA course in 'Medicine, Occupation and Health in Historical Perspective'.
• The Centre also collaborates with the ESRC Centre for Genomics in Society at the university.
• The Centre is also organizing an international conference, 'Health, heredity and the modern home, 1850-2000', to be held in March 2005.
Centre for Medical History at the University Exeter
Wellcome News Q1 2000: Polyptych article on Kate Fisher's research comparing the changing attitudes to sex, marriage and courtship in rural and urban regions of Britain during the last century entitled [brokenlink] Sex in the city
McNeill J (2000) Something New Under the Sun: An Environmental History of the Twentieth Century. London, Penguin
Sheail J (2002) An Environmental History of Twentieth-Century Britain. Basingstoke
Jackson M (ed.) (2003) The Clinical and Laboratory Origins of Allergy. Studies in History and Philosophy of Biological and Biomedical Sciences. Special Issue, 34
Jackson M (2001) Allergy: the making of a modern plague. Clinical and Experimental Allergy 31: 1665-71
Melling J, Mortimer I (2000) The contest between commerce and trade, on the one side, and human life on the other: British Government Policies for the regulation of anthrax infection and the wool textile industries, 1880-1939. Textile History 31: 223-37
Fisher K (2003) They prefer withdrawal: the choice of birth control method in Britain, 1918-1950. Journal of Interdisciplinary History
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