- Doctor, doctor, I think I'm a pack of cards!
- I'm busy, I'll deal with you later....
- Doctor, doctor, will this ointment clear up my spots?
- Well I won't make any rash promises....
- Doctor, doctor, my son swallowed a pen!
- Well just use a pencil until I get there
These are the kind of really bad jokes that young kids (mine, a least) thrive on in the school playground. The doctor doctor joke has been a staple of playtime for generations in the UK, I used to tell them and no doubt my grandchildren will too.
But they all rely on a pretty simple western cultural idea. That when you're ill or you think something might be wrong with you, you go to the doctor. And that's not true quite a lot of the time.
This can be a problem for epidemiologists. Many studies don't rely on their own data but on data that's been collected from a variety of sources such as medical records, and it's hard to study health issues that were never recorded in the first place. The point is that if you have certain problems you might not go to your doctor at all. You might just wait until your symptoms disappear by themselves, go to the chemist and get something, or ask your friends for a recommendation of treatment (this is how a lot of "alternative" practitioners pick up customers - though word of mouth).
The medical data that epidemiologists may rely on is merely the tip of an enormous health iceberg. In the early 1980s Scambler et al made a study of the women on a London housing estate for a period of six weeks, and they found the ratio of symptom episodes to visits to the doctor varied hugely depending on the kind of symptom. For instance, a sore throat or stomach pains resulted in a ratio of 1:9 and 1:11 respectively - that is, every 9 times that sore throats were reported on the survey sheets, 1 person would visit the doctor with a sore throat, and similar for stomach pains. Proportionally, episodes of backache and sleeplessness resulted in trips to the doctor far less, with ratios of 1:38 and 1:31 respectively. Mental health issues were, somewhat unsurprisingly, way down the list. A ratio of just 1:74 women went to the doctor with issues of nerves, depression or irritability.
In 1973, US sociologist Irving Zola conducted interviews in medical clinics in Boston and discovered five triggers for seeking out medical help. First was a personal crisis such as a death in the family, second was if the patient perceived their symptoms were interfering with their personal or social relationships. The third most common reason was, interestingly, pressure from others - your husband nagging you to get that problem seen to, a chance chat with a work colleague showing something isn't as normal as you thought it was. The fourth reason, separate from your social life, was if symptoms were interfering with your paid work or vocation. And finally, my personal favourite, setting a deadline for things to clear up by themselves. We've all done it. The "if it's not better by Tuesday I'll call them" thing.
So what about those ratios, the things that don't fall into Zola's reasons for going to the doctor, the health issues that you either hope will get better by themselves, or self-medicate for? The proportion, compared to what ends up on medical records, is pretty huge. It's terra incognita for epidemiologists. And it's where people's own personal weird and wonderful ideas about health and illness thrive.
Hippocrates (469-377 BCE) was pretty much the forefather of medicine and epidemiology. Like Abraham in The Bible, vast swathes of medical and epidemiological thought branch out from his writings and spread their fronds into the modern world. The primary belief of Hippocrates and his followers was that health was equilibrium, and illness an upset in those delicate bodily balances. The Hippocratic corpus (we're pretty sure that only a small amount was written by the man himself) expounded the idea that the body contained four substances that needed to be kept in equilibrium for health - blood, yellow bile, black bile and phlegm. It must have been pretty easy to see, for the average Hippocratic follower, that your winter cold or flu was an excess of phlegm in the body, or your summer diarrhoea was down to too much black bile. Tied in with the four elements if earth, air, fire and water and various other stuff like the seasons, this belief could give a remarkably complex set of reasons and treatments for particular symptoms.
From a modern perspective, as you read this blog post on your device of choice with all that medical science has to offer reported in the media daily, the whole idea of the four humours seems naive at best, and stupid if you're feeling less charitable. Yet Hippocratic ideas on health have never really gone away. The idea that, after excessive eating or drinking for instance, we need to "detox" or take something to "clear us out" and restore our body's balance is still very common - just visit the shelves of any high street chemist. People talk about "coughing up the rubbish" at the end of a bad cold, or "sweating out" the flu, as if you really were flushing some nasty little squeaking, furious green germs from your system. The idea of restoring your body to equilibrium and, therefore, health is the absolute cornerstone of a multi-million pound over the counter industry with very little evidence that much of it does anything apart from make us feel virtuous.
The whole idea of "virtue" and "deserving" the health we have is another cornerstone of popular belief that has trailed down to us through the centuries, and quite probably another reason for a thriving over-the-counter food supplement industry. People (and sadly, organisations) can make moral judgements on others based on the state of their health. It's for this reason that we occasionally have media debates in the UK on whether the NHS should make smokers pay for their own medical treatment, or whether the state has a "nanny role" to bring down obesity levels through education campaigns. You can see it in reports about people who have developed Type 2 diabetes, or drug or alcohol problems.You can also see it, sadly, in the stigma of sexually transmitted diseases, of AIDS, and increasingly cervical cancer. One if the biggest health stigmas of all is still mental illness - just think back to those one in 74 women in Scambler's study, and how much they must have debated with themselves before going to the doctor, or taking that first step to admitting they had a mental health issue. Too often depression is still seen as an "inability to cope with life" that a "stronger" person would not have, and it must change.
With everyday health issues, it's not only a judgement on other people we can make but on ourselves. In the early 1980s the British doctor and anthropologist Cecil Helman wrote a fascinating study of patients at his GP surgery and their beliefs about mild illnesses. Especially in his older patients, it was a common belief that you "gave yourself" a cold by doing something "silly" like going out with wet hair, a cold draught in your house or stepping in a puddle and having wet feet for the rest of the day. Illnesses that involved fevers, on the other hand, were perceived as "a germ" that was passed onto you by another person and that you needed, literally, to "get it off your chest". People frequently express a need to "loosen" a cough, to "get it all out the system." Helman stated that 6m gallons of cough medicine were distributed via NHS prescription every year, not accounting at all for how much was bought over the counter - yet with very little evidence that it actually does any good.
These everyday mild health complaints, unreported and self-medicated, are not the bread and butter work of epidemiologists very often. Yet they provide an interesting cultural peep into how mon-medical types perceive their own and others' health, and furthermore they might help us to figure out the best way to educate the public through health programmes. Cecil Helman pointed out that GPs often use people's own language to explain their diagnosis to them for simplicity's sake, and he feared that this may embed naive or even false ideas further. But it could also be argued that we need to understand the way people think about illness and health to disillusion them of some false ideas, and that trying not to "blind them with science", while not being patronising, is a fine line. It's also a massive issue in areas of global health, where the western medical tradition's influence is not nearly as strong and some very different ideas may be dominant. Non medical concepts of health and folk remedies may seem piffling to us, but in some places they are the first, or indeed only, recourse.
So next time someone tells you a doctor doctor joke, tell them to make like a pair of curtains and pull themselves together.