Making Sense of "Allergy": More Than One, but Less Than Many

Today I had the pleasure of attending the first in a series of monthly lecture courses for a group of medical residents at a teaching hospital in my city. I attended a few of these classes last fall, so a lot of it is review. Still, I’m excited to review the course to pick up what I missed the first time around and get to know the doctors and students involved a little bit better. I’m also excited to approach the subject matter again, now that I know a lot more about the science of allergy, how allergies are treated, and how people deal with them in daily life.

Already, I see some productive contrasts arising between what I’m (re)learning from physicians and what I talk about with people who are trying to make sense of allergies because it’s part of their lives.

In class tonight, we looked at things that were produced using laboratory techniques, like histological slides (slides with cells stained brightly for identification) and statistical results of how many people experience anaphylaxis under different conditions. We also looked at materials produced through the direct interaction of physicians with patients, like pictures of the inside of sinus cavities taken with a laryngoscope and the results of observational studies of patient outcomes. We talked about the cellular mechanisms by which scientists believe allergies develop: if a protein is presented by antigen presenting cells via the IL-2 pathway to B-cells more than it’s processed via the IL-1 pathway, then an allergy develops. We talked about how different drugs interrupt the allergic response at different points: epinephrine is best for early phase reactions, H1 antihistamines need to be administered before H2 antihistamines, corticosteroids can tamp down late-phase responses.

Earlier this week, I participated in a conversation with a food allergy advocate I’ve slowly been getting to know. One of the things we’ve talked about is what connection different life events, like where a person grows up, might have to developing allergies as an adult. We’ve talked about the biographical details of our lives: where we grew up, what we ate, what medications we took. As we talked, recollections and explanations sometimes blended together. Did that illness cause those later symptoms? Did new symptoms arise at that time in my life, or did they just intensify? We’ve also talked about how our individual life experiences with allergies make us wonder about the consequences of the big stories of modern life in the 20th and 21st centuries: industrialized food production, the modern miracle of antibiotics, and increases in geographic mobility, which we often have no power to resist.

These are very different ways to make sense of allergies.

Both of them are important parts of the story of allergy in the contemporary United States.

I’ve been mulling these contrasts over with reference to the scholarly framework of ontologies. “Ontology” is a fancy word that means “system of classifying things.” We can, and do, classify a disease like allergies in many ways. Allergies are probably partly genetic; they can be considered a form of environmental illness; they involve known biochemical and cellular processes, which can produce allergic reactions; they are a set of symptoms, including hives, swelling of mucosal tissue, and sometimes GI and cardiovascular symptoms, that can be reported to and observed by a physician; they are a disruptive force that shapes an individual’s personal history and narrative about herself.

In the words of one of my favorite scholars, Annemarie Mol, allergies are “more than one, but less than many.” They are all of those things at once, but somehow it doesn’t get confusing when you’re in the moment. In one instance perhaps the life history element is what deserves attention, whereas in another the symptoms matter because a physician is making a diagnosis, or the genetic component is foregrounded when a sibling of an allergic kid has their first reaction. These things coexist when you look at the big picture of what allergies are and what needs to be done about them..

But different people care more or less about different aspects, too. Physicians skew toward caring about clinical trials of medications, epidemiological data, and histology reports. Food allergy bloggers, to take another example, are interested in finding commonalities in their biographies and coming up with ways to assert their political power to make it easier to live with allergies. While these different ways of understanding allergies coexist, they do not coexist evenly. They vary by a person’s training, experience, and needs.

Why does this matter? I think it probably affects what people think it is possible to do about allergies. If your story about allergies focuses on genetics and observational clinical studies, perhaps looking at ways to break the “transmission” of allergies between generations by manipulating maternal diet during pregnancy matters. If  If your experience with allergies is watching your child feel marginalized during classroom activities in which food is served, you might care more about getting politically active and changing policies for serving food in schools. If your experience with allergies includes a growing list of foods you can’t eat, maybe you’ll start to wonder about substances that have recently been introduced to many parts of the food system.

What seems practical to do – and what kind of solution or treatment seems feasible to hope for – probably depends to an extent upon what allergies mean in your life.

I really like the ontology “angle” on medical care, but I’m just starting to understand how it might be helpful for thinking about allergies. As my advisors pointed out years ago, pointing out that and how people classify things is kind of boring. Pointing out how how different classification systems (have the potential to) change how people live, what people value, and what people hope for is more interesting.

What do allergies mean to you? What do you hope for when it comes to medical allergy treatment and the social treatment of people with allergies?

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