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Clinical review
In search of “non-disease”
Richard Smith
The BMJ recently ran a vote on bmj.com to identify
the “top 10 non-diseases.1Some critics thought it an
absurd exercise,2but our primary aim was to illustrate
the slipperiness of the notion of disease. We wanted to
prompt a debate on what is and what is not a disease
and draw attention to the increasing tendency to
classify people’s problems as diseases.
In 1979 the BMJ published a study that did
something similar.3Non-medical academics, medical
academics, general practitioners, and secondary school
students were invited to say whether 38 terms did or
did not refer to a disease. Almost 100% thought that
malaria and tuberculosis were diseases, but less than
20% thought the following to be diseases: lead poison-
ing, carbon monoxide poisoning, senility, hangover,
fractured skull, heatstroke, tennis elbow, colour
blindness, malnutrition, barbiturate overdose, drown-
ing, or starvation (figure). People were split 50:50 over
whether hypertension, acne vulgaris, or gall stones
were diseases. The doctors were more likely to view the
terms as referring to diseases. The authors of this study
included Guy Scadding, who spent much of his life
spelling out to doctors that no general agreement
exists on how to define a disease.
Fourteen years earlier, the New England Journal of
Medicine had published a paper arguing the case for
“non-diseases.4Better, argued Clifton Meador, to
describe a patient in whom a diagnosis could not be
made as having a “non-disease” rather than make “the
common error of continuing to label such patients
with non-existent diseases.” He produced a classifi-
cation of non-disease and concluded that “the
treatment for non-disease is never the treatment
indicated for the corresponding disease entity. In this
statement lies the ultimate value of the science of
non-disease.”
What is a disease?
Thomas Sydenham (1624-1689) thought that diseases
could be classified just like plant and animal species.In
other words, diseases have an existence independent of
Percentage of respondents classifying condition as disease
0
Starvation
Drowning
Barbiturate overdose
Malnutrition
Colour blindness
Tennis elbow
Heatstroke
Fractured skull
Senility
Carbon monoxide poisoning
Lead poisoning
Piles (haemorrhoids)
Depression
Duodenal ulcer
Hay fever
Gall stones
Hangover
Hypertension
Schizophrenia
High blood pressure
Coronary thrombosis
Epilepsy
Alcoholism
Haemophilia
Asthma
Acne vulgaris
Pneumonia
Muscular dystrophy
Multiple sclerosis
Diabetes mellitus
Measles
Emphysema
Poliomyelitis
Syphilis
Cancer of the lung
Tuberculosis
Malaria
Cirrhosis of the liver
10 20 30 40 50 60 70 80 90 100
Non-medical academics (reference group)
Secondary school students
Medical academics
General practitioners
Results of survey in 1979 in which a range of subjects (non-medical
academics, secondary school students, medical academics, and
general practitioners) were asked which of 38 conditions they
considered to be diseases3
Summary points
The BMJ conducted a survey on the web to
identify “non-diseases”
and found almost 200
The notion of “disease” is a slippery one and the
concept of non-disease is therefore similarly
blurred
Health is equally impossible to define
To have your condition labelled as a disease may
bring considerable benefit
both material
(financial) and emotional
However, the diagnosis of a disease may also
create problems
you may be denied insurance, a
mortgage, and employment
A diagnosis may also lead you to regard yourself
as forever flawed and unable to “rise above” your
problem
BMJ, BMA House,
London WC1H 9JR
Richard Smith
editor
BMJ 2002;324:883–5
883BMJ VOLUME 324 13 APRIL 2002 bmj.com
the observer and exist in nature, ready to be
“discovered.” In complete contrast, others see the
notion of disease as essentially a means of social
control.5Doctors define a patient’s condition as a “dis-
ease” and are then licensed to take various actions,
including perhaps incarceration. “Each civilisation,
wrote Ivan Illich, “defines its own diseases. What is sick-
ness in one might be chromosomal abnormality, crime,
holiness, or sin in another.6
The Oxford Textbook of Medicine wisely stays away
from defining a disease. The Chambers Dictionary
defines disease as “an unhealthy state of body or mind;
a disorder, illness or ailment with distinctive symptoms,
caused eg by infection.”Neither definition is operation-
ally helpful, especially as health is even harder to define
than disease. Imre Loeffler, surgeon, essayist, and wit,
says that the World Health Organization’s famous defi-
nition of health as “complete physical, psychological,
and social wellbeing” is achieved only at the point of
simultaneous orgasm, leaving most of us unhealthy
(and so, by the Chambers Dictionary definition, diseased)
most of the time.
Disease is often defined as a departure from
“normal,” and helpfully David Sackett and others offer
six definitions of normal in Clinical Epidemiology, “the
bible of evidence based medicine”(table 1).7One com-
mon definition is that you lie more than two standard
deviations from the mean on whatever measure is
used
height, weight, haemoglobin concentration, and
tens of thousands of others. By definition,5% of people
are thus “abnormal” (and we might say diseased) on
each test. Run enough tests and we are all abnormal
(diseased). Or, on a definition of increased risk, we
might define almost the entire population of Britain as
diseased if we consider all those with a blood
cholesterol concentration that carries an extra risk of
mortality compared with the cholesterol concentration
of those living in less developed communities.
The pluses and minuses of having a
disease label
To have your condition labelled as a disease may bring
considerable benefit. Immediately you are likely to
enjoy sympathy rather than blame. You may be
exempted from many commitments, including work.
Children learn very young that saying you have a
headache will bring sympathy and a hug, whereas say-
ing, “I can’t be bothered to go to school” will bring
anger and punishment. Having a disease may also
entitle you to benefits such as sick pay, free
prescriptions, insurance payments, and access to facili-
ties denied to healthy people. You may also feel that
you have an explanation for your suffering.
But the diagnosis of a disease may also create many
problems. It may allow the authorities to lock you up or
invade your body. You may be denied insurance, a
mortgage, and employment. You are forever labelled.
You are a victim. You are not just a person but an asth-
matic, a schizophrenic, a leper, an epileptic. Some dis-
eases carry an inescapable stigma, which may create
many more problems than the condition itself. Worst
of all, the diagnosis of a disease may lead you to regard
yourself as forever flawed and incapable of “rising
above” your problem.
Consider the case of alcoholism, a hotly disputed
diagnosis. Better perhaps to be “an alcoholic” than a
morally reprehensible drunk. But is it helpful to think
of yourself as “powerless over alcohol,” with your prob-
lem explained by faults in your genes or body chemis-
try? It may lead you to a learned and licensed
helplessness.
Illich puts it like this this6:
“In a morbid society the belief prevails that defined and
diagnosed ill-health is infinitely preferable to any other
form of negative label or to no label at all. It is better
than criminal or political deviance, better than laziness,
better than self-chosen absence from work. More and
more people subconsciously know that they are sick
and tired of their jobs and of their leisure passivities, but
they want to hear the lie that physical illness relieves
them of social and political responsibilities. They want
their doctor to act as lawyer and priest. As a lawyer,the
doctor exempts the patient from his normal duties and
enables him to cash in on the insurance fund he was
forced to build. As a priest, he becomes the patient’s
accomplice in creating the myth that he is an innocent
victim of biological mechanisms rather than lazy,
greedy, or envious deserter of a social struggle over the
tools of production. Social life becomes a giving and
receiving of therapy: medical, psychiatric, pedagogic, or
geriatric. Claiming access to treatment becomes a
political duty, and medical certification a powerful
device for social control.”
“There is no disease that you either have or don’t
have
except perhaps sudden death and rabies. All
other diseases you either have a little or a lot of.”
Geoffrey Rose epidemiologist
Table 1 Six definitions of “normal” in common clinical use7
Property Term Consequences
Distribution of diagnostic test results has a certain shape Gaussian Ought to occasionally obtain minus values for
haemoglobin, etc
Lies within a preset percentile of previous diagnostic test results Percentile All diseases have the same prevalence. Patients are
normal only until they are “worked up”
Carries no additional risk of morbidity or mortality Risk factor Assumes that altering a risk factor alters risk
Socially or politically aspired to Culturally desirable Confusion over the role of medicine in society
Range of test results beyond which a specific disease is, with known
probability, present or absent
Diagnostic Need to know predictive values that apply in your
practice
Range of test results beyond which treatment does more good than harm Therapeutic Need to keep up with knowledge about treatment
“I don’t know why you say that making a diagnosis is
the most important thing a doctor does. As a general
practitioner I hardly ever make a diagnosis.
General practitioner north London
Clinical review
884 BMJ VOLUME 324 13 APRIL 2002 bmj.com
The BMJ s vote
We began our search for non-diseases by generating
our own definition and list. By “non-disease” we meant
“a human process or problem that some have defined
as a medical condition but where people may have
better outcomes if the problem or process was not
defined in that way.” This exercise prompted an
internal debate about whether we were insulting those
who might regard themselves as having what others
might classify as a non-disease.
We responded by making clear that we were not
suggesting that the suffering of people with these
“non-diseases” is not genuine. The suffering of many
with “non-diseases” may be much greater than those
with widely recognised diseases. Consider the
suffering that might come from grief, loneliness, or
redundancy.
Having generated our own list, we then invited sug-
gestions from our editorial board. We were surprised
that we quickly achieved a list of nearly 100. Next,
readers were invited to add to the list, boosting it to
nearly 200.
Paul Glasziou, a general practitioner from Queens-
land, Australia, and a member of the BMJ editorial
board, has used most of these to produce an ICND
an
international classification of non-diseases (table 2).
Deliberately, but perhaps unwisely, we allowed almost
anything to be added to the list, including some “non-
treatments” like circumcision. A list of non-treatments
might be even longer than a list of non-diseases. Then
came the vote for the top 10 non-diseases, and the box
shows the top 20.
The complete list is interesting, and I was surprised
that we could generate so many non-diseases.Some of
these non-diseases already appear in official classifica-
tions of disease, and perhaps those that do not
currently appear will be appearing soon. Disease
classifications are likely to grow not shrink, particularly
as genetics begins to allow the separation of what are
currently single diseases into many.
What mattered most about this process, however,
was not the list but the debate. Rapid responses to the
debate are summarised on p 913. Surely, everything is
to be gained and nothing lost by raising consciousness
about the slipperiness of the concept of disease.
Competing interests: None declared.
1 http://bmj.com/cgi/content/full/324/7334/DC1
2 Bailey M.How to use an esteemed medical journal to increase suffering.
http://bmj.com/cgi/eletters/324/7334/DC1
3 Campbell EJM, Scadding JG, Roberts RS. The concept of disease. BMJ
1979;ii:757-62.
4 Meador CK. The art and science of nondisease. N Engl J Med 1965;
272:92-5.
5 Foucault M. The birth of the clinic. New York: Pantheon, 1973.
6 Illich I. Limits to medicine. London: Marion Boyars, 1976.
7 SackettDL, Haynes RB, Guyatt GH, Tigwell P. Clinical epidemiology: a basic
science for clinical medicine. Boston: Little, Brown: 1991:59.
Table 2 International classification of non-diseases, based on non-diseases suggested to bmj.com
Aesthetic discomfort Current discomfort or dysfunction
Possible future discomfort,
dysfunction, or death
Misattribution or
diagnosis
Anxiety about size Allergy to 21st century; chronic candida infection; false memory
syndrome; flat feet; Gulf war syndrome; multiple chemical sensitivities;
total allergy syndrome
Universal Ageing; skin wrinkles Ageing; ignorance; loneliness; menopause; teething; unhappiness; work Menopause
Usual response Acne; bags under the eyes;
borborygmi; stretch marks
Adjustment reaction; bereavement; boredom; childbirth; jet lag;
hangover; pain; pregnancy; whiplash
Whiplash
Ends of spectrum Big ears; dandruff; gap teeth; grey
or white hair; halitosis; obesity;
ugliness
Air rage; alcohol dependency; anorexia; attention deficit disorder; bed
wetting; burn out; chronic fatigue syndrome; colic; domestic violence;
dyslexia; fibromyalgia; personality disorder; perimenstrual dysphoric
disorder; procrastination; road rage; seasonal affective disorder; stress;
teenage pregnancy
Hypercholesterolaemia
Variant of normal Baldness; cellulite; freckles;
skin tags
Chinese restaurant syndrome; conduct disorders in childhood; ear wax
accumulation; food intolerance; infertility; nail chewing; teeth grinding;
tension headaches; tics
Deviation of nasal septum;
smoking
Top 20 non-diseases (voted on bmj.com by
readers), in descending order of
“non-diseaseness”
1 Ageing
2 Work
3 Boredom
4 Bags under eyes
5 Ignorance
6 Baldness
7 Freckles
8 Big ears
9 Grey or white hair
10 Ugliness
11 Childbirth
12 Allergy to the
21st century
13 Jet lag
14 Unhappiness
15 Cellulite
16 Hangover
17 Anxiety about penis size/
penis envy
18 Pregnancy
19 Road rage
20 Loneliness
Endpiece
The best part of the cure
He consulted a new physician . . . who bluntly
diagnosed all his symptoms as “evils produced by
the use of narcotics.” He prescribed mercury in the
form of Corbyn’s Blue Pills, nitric acid in water, and
a “known & measured quantity of Stimulant, with
an attempt to diminish the Opiate part of it little by
little, if it were only a single Drop in two days.”But
Coleridge felt the sickness was in his heart, and the
best part of the cure lay simply in talking to the
doctor and trying to put him “in possession of the
whole of my Case with all its symptoms, and all its
known, probable and suspected Causes.
Richard Holmes. Coleridge—Darker reflections.
London: HarperCollins, 1998
Submitted by Iona Heath,
general practitioner, London
Clinical review
885BMJ VOLUME 324 13 APRIL 2002 bmj.com
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The connotations of the term "a disease" were investigated by studying the ways in which both medical and non-medical people used the word. A list of common diagnostic terms was read slowly to groups of non-medical academic staff of a university, secondary-school students, medical academics, and family practitioners, who then indicated whether they thought each word referred to disease.All groups rated illnesses due to infections as diseases, but the doctors, and particularly the general practitioners, were more generous in accepting as diseases the terms for non-infectious conditions. Apart from the nature of the cause, the most influential factor in determining whether or not an illness was considered to be a disease was the importance of the doctor in diagnosis and treatment.These findings provide further evidence that there is ambiguity about the meaning of the term disease. To the layman a disease seems to be a living agency that causes illness. Doctors have obviously accepted more heterogeneous defining characteristics but remain reluctant to adopt unequivocally nominalist ways of thought. The position is not unlike that in the physical sciences, in which there is a good precedent for distinguishing between the formal scientific and the everyday uses of terms such as "force" and "power."
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I might have guessed that a book dedicated to "H.L. Mencken, Kurt Vonnegut, Jr., Douglas Adams, and the Emperor's New Clothes" would be fun to read. It was! Readers will sense the authors' enthusiasm for their subject on each page, from the preface to the final chapter. The authors prepared this book for "users" rather than "doers" of clinical research. Physicians and others who wish to recognize key clinical epidemiologic features of the diagnosis and management of patients will benefit from reading Clinical Epidemiology. Those who wish to conduct actual research studies will need to look elsewhere for a detailed discussion of clinical epidemiologic methodology. In this review, I will mention some strengths and limitations of the book and recommend it to particular audiences. The book's primary strengths are the clear and practical explanations for an array of epidemiologic concepts ranging from sensitivity and specificity to "zero-time shift" and "inception
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FOR the physician accustomed to dealing only with pathologic entities, terms such as "nondisease entity" or "nondisease" are foreign and difficult to comprehend. This paper will present the background for the development of this new science, a classification of nondisease and finally the important therapeutic principles based on this concept. Since disease is an abnormal state that lends itself to classification into syndromes and entities, one tends to think of health or nondisease as all encompassing and without specificity. This is not the case, since it is now clear that "nondisease" may be used in quite a specific manner; furthermore, . . .
How to use an esteemed medical journal to increase suffering
  • M Bailey
Bailey M. How to use an esteemed medical journal to increase suffering. http://bmj.com/cgi/eletters/324/7334/DC1
Clinical epidemiology: a basic science for clinical medicine
  • D L Sackett
  • R B Haynes
  • G H Guyatt
  • P Tigwell
Sackett DL, Haynes RB, Guyatt GH, Tigwell P. Clinical epidemiology: a basic science for clinical medicine. Boston: Little, Brown: 1991:59.