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The three aspects of malady.

The English language has the luxury of having four different words that describe deficient health states: disease, illness, sickness, and malady. Malady is a term that is not used very often and it does not have a specific denotation: the other three terms do. It is customary to use the word disease in a medical sense, referring to the medical definition of a condition that negatively affects the functioning of an individual. The medical definition will include references to laboratory findings and to the (diminished) performance of different body systems. Usually, the definition of a disease will include notions about causative and risk factors, ideas about the way in which the pathological processes develop, statements about the prognosis, and reactions to different treatments. 
 
The word illness is used to describe what persons feel about themselves. They describe their feelings in various ways, sometimes referring to a particular organ (in France, the liver is often seen as being at the bottom of things, the reason for feeling ill; the Slavs use the same word for life and the stomach and complain about its malfunction, Iranians and others refer to their heart, and so on). Sometimes, when feeling ill, patients are uncertain what words to use to describe their state and will choose words that they feel attract the attention of their doctor or their family. Thus, when seeking help from doctors, they will refer to pain in organs and when speaking to their family they will talk about functioning, complain of being tired, unable to do things, and so forth. 
 
Sickness is a word describing yet another aspect of not being in good health. It refers to the societal recognition of the state of illness. Societies recognize certain states of dysfunction and disease as being sufficiently important to be given sickness benefits that include the permission to be absent from work, reimbursement for expenses incurred in the process of treatment and possibly other support. 
 
Unfortunately, the three terms do not cover the same territory. They overlap to an extent that will vary from country to country and from one social group to another. Some people who have a disease do not feel ill. Some of those who feel ill or even very ill do not seem to have any physical reason for it, no tissue damage, no dysfunction in the main body systems. Sometimes, sickness will cover people who are neither diseased nor feel ill: such was the case with the psychiatric treatment of dissidents. In some instances people have a disease that is not being recognized by society as being sufficiently important to receive sickness benefits. 
 
A number of questions arise from this conundrum. Should people who say that they are feeling ill without having any demonstrable tissue damage be considered as malingerers? Should we try to discover an untreatable disease in people who do not feel ill? What should be done to assess needs for care – count the numbers of people who feel ill (and will come forward to seek help), or count those who have a medically diagnosable disease regardless of how they feel? Or define needs on the basis of epidemiological studies that define a case in accordance with the official definition of sickness? And how should we evaluate the success of a health service – by establishing whether the population is satisfied (because those who feel ill have received help)? Or should we be considering that a service is successful if all the people who have a disease have been reached regardless of whether they need or want any help from the health service system? 
 
There are conditions that would be considered a sickness by society, a disease by the medical profession and an illness by those who suffer from them. Their number, however, is not all that large as one would think and for conditions that do not fall into this group the questions listed above (and many others) will arise. There is no strict rule that could be followed to answer them nor is it possible to reject any of the three definitions. It is therefore necessary that physicians and public health decision makers remain aware of the three aspects (and territories) of maladies with which they are dealing even if that complicates their life and their actions. Such is the world in which we live.