Constructing RSI: Belief and Desire

A Dallas taxi driver once helpfully informed me that 90% of Americans were sick. He explained that it was all down to liver disease and that the medicine in the boot of his car was going to cure the nation. His statistics were not outrageous. Physical symptoms are certainly common in the general population, but their persistence, the distress that they cause, and their significance to the individual are not necessarily explained by underlying disease.

Figure 1.

Yolande Lucire

University of New South Wales Press, $AS49.95, pp 216 ISBN 0 86840 778 X www.unswpress.com.au/

Rating: ★★

Psychological factors afford one level of explanation, either because they may cause physical symptoms directly (anxiety's effect on the heart, for example) or because psychological distress may be felt and expressed as physical symptoms (somatisation). A further explanation comes at the level of society and culture in the notion that the significance and meaning, to an individual, of commonly experienced symptoms may be influenced by what is going on in the world at large.

An example of this last level of explanation lies at the core of this book, an account of the sudden appearance and dramatic rise of a new syndrome, repetitive strain injury (RSI), in Australia in the 1980s. The author argues that this diagnosis was established by an alliance of doctors and union officials in the context of concern about working conditions and the new technology of the computer keyboard, but in the absence of any scientific basis for the existence of the disease itself. The syndrome was well publicised and the result, Lucire claims, was the equivalent of an epidemic, as workers presented their symptoms for scrutiny and compensation under the new label.

The story presents a depressingly familiar litany of reasons for the confrontations that ensued: doctors too willing to apply spurious pathological labels to symptoms; the law fixated with the notion that medical diagnoses are an arbiter of truth about the severity of people's symptoms and disability; and the persisting belief that managing a workplace symptom such as arm pain as a disease, independent of social and psychological circumstances, will make the problem go away. The confrontations between Lucire the psychiatrist and claimants with arm symptoms also illustrate how, just at the point where biology is uncovering the mechanisms of how social and mental events cause bodily symptoms, we are far from having a common language that pulls body and mind together and communicates to patients that symptoms such as pain do not somehow become trivial or pejorative in the absence of a physical diagnosis.

But the main message of the book is that cultural change has the capacity to influence the experience and presentation of symptoms. Symptoms are not simple reflections of the prevalence of a disease in a population. Their expression and significance depend on such things as how we as a society define ill health, approach disability in the workplace, or compensate for symptoms—all matters that are as much moral, political, and economic, as medical. This is a tricky issue. The encouragement to seek compensation for injury may produce justice for ill people, but it may also turn symptoms into illness, and make ill people more ill. Lawyers may be bad for your health. And what the RSI epidemic reminds us above all is that the traditional biomedical model still dominates much legal, medical, and popular culture.

Lucire's book provoked me to think it provides a route to interesting historical literature, and to much detail, anecdote, and reference about this intriguing epidemic. But there is a lack of logic, consistency, and objectivity in the author's analysis, and her own study of litigants seems to have no stronger basis to it than many of the studies she condemns. Perhaps this is the result of distilling a dissertation into a book, but it seems likely that the author's own position and role in the affair—only revealed late on—has influenced this informed but partial view.