Introduction
A patient arrives at a clinic in Seoul describing a lump pushing up under the breastbone, heat rising to the face, and a weight on the chest built up over years of swallowed anger. A physician trained in biomedicine runs the standard tests, finds no tumor and no measurable lesion, and concludes that nothing is physically wrong. A physician trained in Korean traditional medicine, hanbang, hears the same complaint and recognizes hwabyeong, literally fire illness, a condition with a name, a cause, and a treatment. The patient has not changed between the two encounters. What has changed is whether the suffering counts as a disease.
This gap sits at the center of medical anthropology. In a 1978 paper, Arthur Kleinman, Leon Eisenberg, and Byron Good drew a distinction that has shaped the field since (Kleinman et al., 1978). Disease, in their scheme, is the malfunction of biological processes as biomedicine defines it. Illness is the human experience of symptoms, the way a person and their family live with feeling unwell. The two do not always line up. A person can have disease without illness, as with symptomless high blood pressure, or illness without disease, as with the Seoul patient whose suffering is real but whose body shows no biomedical fault. Allan Young later added a third term, sickness, the process by which a condition becomes socially recognized and given a public identity (Young, 1982). It is this third process that the paper examines.
The central research question is this: by what mechanisms does Oriental medicine convert biomedically illegible distress into a legitimate, named, and treatable category, and under what conditions does biomedicine absorb, ignore, or reclassify those same categories? The question cuts against a common assumption that a real disease is simply one biomedicine can detect and that everything else is imaginary or merely cultural. If traditional systems turn contested suffering into recognized conditions through describable social mechanisms, and if biomedicine appears to rely on the same mechanisms, then the boundary between a folk illness and an official disease is not drawn by biology alone.
To pursue this question, the paper anchors on one condition, hwabyeong, and reads it against parallel categories in Chinese medicine. Hwabyeong suits the task unusually well. It was listed in the glossary of culture-bound syndromes in the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, which gave it a rare foothold inside biomedical psychiatry, and it has a substantial research literature in both Korean and English (Lin, 1983; Min et al., 2009; Suh, 2013). The Chinese categories set against it, neurasthenia, stagnation, and shanghuo, let the analysis separate what is specific to Korea from what is shared across East Asian medicine (Kleinman, 1982; Pan et al., 2020).
The paper’s contribution is a framework rather than a summary. From the comparison it builds a model of three legitimation pathways through which distress becomes disease, naming, embodiment, and institutionalization, and a matching typology of three biomedical responses, absorption, indifference, and repathologization. The stance is analytic rather than evaluative. The goal is not to decide whether Oriental medicine is medically correct, a question this paper cannot settle, but to describe how legitimation works and to ask how far it reaches beyond traditional systems.
Each pathway has a precedent, so the framework’s originality rests on the combination rather than the parts. Naming draws on Kleinman’s account of diagnosis as intervention and on Hacking’s looping effects; embodiment on Scheper-Hughes and Lock and on Nichter; institutionalization on Leslie and Scheid. None of these accounts explains how the three act on one another. Hacking shows how a label reshapes the people it names but says little about why some labels acquire clinical standing. The embodiment literature explains why bodily idioms persuade, not why persuasion alone is insufficient in a clinic. The institutional literature explains how professions secure categories but takes the categories as given. Read as a sequence, the three specify an order in which each stage supplies what the previous one cannot, and that sequence is what the paper contributes.
Materials and Methods
This study is a structured comparative literature review. Rather than testing a hypothesis with new data, it treats existing scholarship as its evidence base and compares cases in order to build an analytic framework. The approach suits the phenomenon at issue, since the social conversion of illness into disease has been documented in scattered form across disciplines that seldom cite one another. The contribution lies in connecting them.
Three bodies of literature were selected because each addresses one face of the research question while leaving the others underdeveloped. The first is the illness, disease, and sickness tradition in medical anthropology, including Kleinman’s explanatory-model framework, Young’s account of socialization into sickness, and the embodiment theories of Scheper-Hughes and Lock (Kleinman et al., 1978; Scheper-Hughes & Lock, 1987; Young, 1982). It supplies the core vocabulary but says little about the machinery of legitimation. The second is the debate over culture-bound syndromes and their successor concept, cultural concepts of distress, running from Simons and Hughes through Nichter to the fifth edition of the Diagnostic and Statistical Manual (American Psychiatric Association, 2013; Lewis-Fernandez & Kirmayer, 2019; Nichter, 1981, 2010; Simons & Hughes, 1985). It is rich on classification but treats traditional categories as objects to be sorted rather than as achievements. The third is the history and ethnography of East Asian medicine, including Kuriyama, Farquhar and Scheid on Chinese clinical practice, and Suh’s history of hwabyeong (Farquhar, 1994; Kuriyama, 1999; Scheid, 2002; Suh, 2013). It is deep on East Asian specifics but rarely engages the general theory of legitimation. The first two are used mainly as theoretical scaffolding, while the third, with the clinical studies of hwabyeong and neurasthenia, supplies the empirical material about the cases. Where a source does both, as Kleinman (1982) does, the text indicates which role it is playing.
Searching was carried out between March and May 2025 in PubMed, JSTOR, and Google Scholar. The principal search strings paired a condition term (hwabyeong OR hwa-byung; shenjing shuairuo OR neurasthenia; shanghuo) with a conceptual term (culture-bound syndrome; idioms of distress; somatization; legitimation; medicalization; Korean OR Chinese traditional medicine). Citation chaining ran in both directions from two keystone works, Suh (2013) for Korea and Kleinman (1982) for China: reference lists backward, citing articles forward through 2024. No publication-date limit was imposed, since the argument depends on tracing categories historically, but sources had to be available in English, a restriction noted below. Approximately fifty candidates were screened. A source was retained if it supplied primary evidence about one of the case categories, supplied a concept the framework uses, or documented an institutional decision about classification. Sources were set aside when a stronger source covered the same ground, when they reported clinical outcomes with no bearing on how a category is recognized, or when they mentioned the cases in passing. Several Korean-language studies by Min and colleagues are cited indirectly through Suh (2013), for want of stable English-language identifiers, and pharmacological studies are used only as evidence of how traditional systems operationalize treatment, not as evidence about cultural meaning.
The comparative framework proceeds in three steps. First, the two case literatures, Korean and Chinese, are read against each other to identify shared mechanisms of legitimation. Second, those mechanisms are abstracted into a three-part model. Third, the model is extended to biomedicine by asking whether its own categories appear to travel the same pathways, with the reflexive turn in recent psychiatric classification as the illustration. This is an interpretive extension rather than a test: no independent sample of biomedical diagnostic histories was assembled, no coding scheme was applied in advance, and no comparison was made against rival explanations, so systematic testing across further cases remains for future work. Disagreements in the literature, especially the somatization debate, are treated as analytic resources rather than problems to be resolved.
The three Chinese categories were chosen because each isolates a different part of the comparison, not because they form a single class. Neurasthenia, or shenjing shuairuo, is the closest analogue to hwabyeong: a named condition with a clinical literature and a disputed relationship to depression, which makes it the sharpest case for repathologization. Stagnation is a classical pattern internal to Chinese medicine, included because it shows the embodiment pathway working with no biomedical counterpart. Shanghuo is a popular rather than a professional category, included because it is the case biomedicine has largely left alone. Their histories differ, so grouping them in one column of Table 1 is a compression, flagged where it bears on the argument.
Results
The comparison yields three findings: a recurring set of legitimation pathways, a patterned range of biomedical responses, and a set of live contradictions in the literature that the framework helps explain.
The three legitimation pathways. In both the Korean and Chinese cases, the conversion of illness into recognized disease travels through three mechanisms that recur independently of the condition. The first is naming. Giving diffuse suffering a bounded label transforms it from a private complaint into a shareable object. Kleinman, Eisenberg, and Good argued that a diagnosis is an intervention rather than a description, because it reorganizes how the sufferer, the family, and the healer understand what is happening (Kleinman et al., 1978). Hwabyeong shows this. The word packages a cluster of experiences, suppressed anger, chest heaviness, heat, and a felt epigastric mass, into a single culturally legible entity that patients recognize in themselves and can present to a healer (Lin, 1983; Park et al., 2002).
Naming does more than describe; it can bring a category into being. Ian Hacking’s account of looping effects holds that when a new label enters circulation, people begin to experience and present themselves in terms of it, so that the classification and the classified change together (Hacking, 1995). Suh’s history of hwabyeong shows the loop in motion. The classical Korean texts, including the seventeenth-century Tongui bogam and the nineteenth-century constitutional medicine of Yi Che-ma, contained no such disease category; the modern diagnosis was assembled in the late twentieth century by braiding a folk term for fire-related suffering together with the imported category of depression (Suh, 2013). The name is a recent achievement rather than a timeless survival, and it then shaped who came to have the condition.
The second pathway is embodiment. A category gains legitimacy when it is anchored in the body rather than dismissed as being in the mind. Scheper-Hughes and Lock’s account of the mindful body rejects the Cartesian split between physical body and mental self, holding that social distress is lived through and expressed in the body (Scheper-Hughes & Lock, 1987). Oriental medicine is well equipped for this because its physiology never separated emotion from organ. In its framework, anger is a movement of fire and energy through specific organ systems, so emotional suffering has a bodily location and a physiological grammar by default (Kuriyama, 1999). Hwabyeong’s signature complaint, rising heat and a mass beneath the breastbone, is a bodily idiom of this kind, what Nichter called an idiom of distress, a culturally shaped language for what may not be sayable in words (Nichter, 1981, 2010).
Embodiment also protects a category from the charge of being imaginary without requiring a biomedical lesion. Margaret Lock’s concept of local biologies matters here. Studying menopause in Japan and North America, Lock found that even hormonally mediated symptoms differ measurably across populations, so bodily experience is shaped by local biology and culture together rather than interpreted differently after the fact (Lock, 1993, 2001). Two ideas can then be held at once: hwabyeong can be a real bodily experience with physiological correlates, and it can lack any single lesion that biomedicine would recognize as its cause. The embodiment pathway legitimizes the illness by placing it in the body without waiting for biomedicine’s permission.
The third pathway is institutionalization. A category becomes durable when institutions ratify it: licensing bodies, diagnostic manuals, professional associations, and the state. Charles Leslie’s comparative study showed that traditional medicine in Asia was never a marginal folk practice but an organized, literate, state-linked profession (Leslie, 1976). In contemporary Korea and China that standing is formalized: traditional physicians are licensed, and traditional categories circulate inside official health systems. Volker Scheid’s ethnography describes how Chinese diagnostic patterns are negotiated with and standardized by a state that both promotes and regulates them (Scheid, 2002). Suh shows the Korean parallel, in which hanbang physicians and psychiatrists competed to claim hwabyeong, traditional practitioners appealing to nationalist arguments about indigenous medicine to secure it as their own (Suh, 2013). Min and colleagues completed the institutional move by publishing formal diagnostic criteria and validated instruments for hwabyeong, the apparatus that marks a condition as an object of clinical science (Min et al., 2009; Roberts et al., 2006).
These three pathways are analytically distinct but mutually reinforcing. Naming makes suffering shareable, embodiment makes it real, and institutionalization makes it durable. Table 1 summarizes the model and maps each pathway onto the Korean and Chinese cases.
The three biomedical responses. When a legitimized traditional category meets biomedicine, the literature shows three patterned responses, set out here as ideal types that actual cases may fall between. Absorption is present when a biomedical institution takes the traditional category into its own classification under its own name. Repathologization is present when it accepts the reported suffering but substitutes an established biomedical diagnosis for the traditional explanation. Indifference is present when it does neither, leaving the category outside both the classifications and the research literature. The three can coincide: hwabyeong was listed in a diagnostic manual while much of the clinical literature read it as depression. The listing of hwabyeong in the glossary of culture-bound syndromes in the fourth edition of the Diagnostic and Statistical Manual is a case of partial absorption: psychiatry acknowledged the category by name while quarantining it as culturally specific rather than universal (American Psychiatric Association, 2013; Lin, 1983). Indifference appears in the Chinese popular concept of excess fire, shanghuo, which maps onto no lesion and makes no institutional demand; it circulates widely in everyday life and traditional practice but has attracted almost no attention from biomedicine, and even traditional pharmacology concedes that it lacks a systematic theoretical basis (Luo et al., 2021; Pan et al., 2020). The evidence here is an absence, which carries less weight than the evidence for the other two: the silence establishes that shanghuo has not been taken up, not that biomedicine has taken a position on it.
The third response is repathologization, in which biomedicine accepts that something real is present but reclassifies it under its own diagnostic label, effectively renaming the condition on its own terms. It is the most consequential response and the site of the sharpest debate. Kleinman’s study of neurasthenia in China argued that most patients carrying the traditional diagnosis met the criteria for major depressive disorder, so that neurasthenia was, in his reading, a culturally shaped presentation of depression (Kleinman, 1982). On this account biomedicine does not absorb or ignore the traditional category but translates it, converting a local disease back into a universal one. The same pattern appears in the Korean data: among eighty-nine patients who identified themselves as having hwabyeong, roughly half met the criteria for major depressive disorder and about two thirds carried some depressive-disorder diagnosis, which invites the same repathologizing move (Min et al., 2009).
Live contradictions in the literature. The framework does not dissolve the field’s disagreements; it locates them. Three remain open. The first is the somatization debate. Against Kleinman’s translation of neurasthenia into depression, Sing Lee argued that the reasoning assumes the universality of the Western category, and that the shift from neurasthenia to depression in China was driven less by scientific discovery than by professional and pharmaceutical interests, including the availability of drugs marketed for depression (Lee, 1994, 1999). On Lee’s account, what looks like biomedicine detecting a hidden truth is better described as biomedicine imposing its own category, a process he warns can teach a somatic sufferer to psychologize distress. That the two later co-authored a partial reconciliation shows the debate is open rather than settled (Lee & Kleinman, 2007). In the model developed here, this is the ambiguity of the repathologization response: whether it is discovery or imposition cannot be read off the clinical data alone.
The second contradiction concerns hwabyeong’s status. Min’s research program treats it as a distinct anger syndrome with its own criteria, yet its own data show heavy overlap with depression (Min et al., 2009; Min & Suh, 2010). The residual matters most: a small share of self-identified hwabyeong patients met no biomedical diagnosis at all yet still claimed the condition, which is the pure form of illness without disease that this paper set out to examine. Whether these patients have a distinct disorder, a variant of depression, or a legitimate illness with no corresponding disease is the question the framework reframes rather than closes.
The third contradiction is the coherence of the culture-bound category itself. The concept was built to mark certain conditions as bound to particular cultures, implicitly treating Western diagnoses as culture-free by contrast (Kenny, 1988; Simons & Hughes, 1985). The fifth edition of the Diagnostic and Statistical Manual retired the term in favor of cultural concepts of distress and conceded that all forms of distress are locally shaped, including its own disorders, and that many established diagnoses began as cultural prototypes that gained acceptance through clinical usefulness (American Psychiatric Association, 2013; Lewis-Fernandez & Kirmayer, 2019). That admission, from the central institution of biomedical psychiatry, is the strongest evidence for the claim developed below, that the legitimation pathways are not peculiar to Oriental medicine.
Discussion
The comparison supports three claims. The first is that Oriental medicine legitimizes biomedically illegible distress through a describable and repeatable process, not through vagueness or mystery. Naming, embodiment, and institutionalization are concrete mechanisms, and they operate similarly in the Korean and Chinese cases despite the differences between the conditions. Hwabyeong and neurasthenia are not the same illness, but they are made into diseases the same way. This is itself a finding: the machinery of legitimation is more stable across the region than the categories it produces.
The second claim is that biomedicine’s response to these categories is patterned and predictable. Whether biomedicine absorbs, ignores, or repathologizes a traditional category appears to depend less on the reality of the suffering than on two institutional facts: whether the category makes a claim biomedicine must answer, and whether biomedicine has a tool, usually a drug, that fits it. Shanghuo is ignored because it demands nothing of biomedicine. Neurasthenia and hwabyeong are repathologized because depression offers a ready translation with a matching treatment, which is the pharmaceutical logic Lee identified (Lee, 1999). Absorption, as in the manual’s glossary, occurs when a category is too visible to ignore but too foreign to fully naturalize. The boundary of biomedical disease is drawn in part by the shape of biomedical institutions and their toolkits, not by biology alone.
The third claim is that the legitimation pathways are not unique to Oriental medicine. Brought together, the three literatures produce something none of them states on its own. The medical-anthropology tradition gives the illness and disease distinction but leaves biomedicine’s own categories unexamined. The East Asian medicine scholarship shows legitimation at work in traditional systems but rarely turns the lens back on biomedicine. The psychiatric classification debate has arrived at a reflexive admission, that biomedical diagnoses are themselves locally shaped and began as cultural prototypes, without connecting it to the anthropology of traditional medicine (American Psychiatric Association, 2013; Lewis-Fernandez & Kirmayer, 2019). Placed side by side, the three literatures point toward a conclusion each approaches but none completes: the same three pathways that turn hwabyeong into a disease may also be at work when biomedicine turns distress into diagnosis. Depression, too, was named, embodied through an evolving physiology of neurotransmitters, and institutionalized through manuals and licensing. On this reading the difference between a folk illness and an official disease is less a difference in kind than a difference in the reach and authority of the institutions doing the legitimating. Two qualifications keep the claim in bounds. Social legitimation and biological reality are not alternatives: a category can be institutionally produced and still track real physiological processes, and a culturally specific category can pick out a genuine experience without corresponding to any single lesion. The evidence is also thin for a claim of this scope, resting on two East Asian cases and a reading of psychiatric classification, enough to propose the parallel and not to establish it. Institutional authority is one determinant of diagnostic legitimacy, not the only one.
The reframing has a practical consequence. If the residual hwabyeong patients who meet no biomedical diagnosis are dismissed as having nothing wrong, their suffering goes unaddressed; if their illness is recognized through the process that legitimizes any diagnosis, it can be treated within a pluralistic system. Leslie’s point that cosmopolitan biomedicine is itself one medical system among others, not the neutral standard against which the rest are measured, is what makes this possible (Leslie, 1976). The analysis does not claim that hwabyeong and depression are the same, nor that Oriental medicine’s physiology is biomedically correct. It claims that the process by which each becomes a recognized disease looks similar in both, and that this process does substantial work in separating the conditions we call real from those we call merely cultural.
Several limitations qualify these claims. The framework is built from two East Asian cases and may not extend to other regions or traditions without modification. The empirical basis for the embodiment pathway remains theoretical for hwabyeong, since no biomarker or neuroimaging study establishes a distinct physiological signature, and a recent machine-learning study of vulnerability is suggestive rather than conclusive (Kwon et al., 2024). Much of the primary Korean-language research was accessed through secondary synthesis, which introduces the interpretive choices of intermediate authors, and the English-language restriction compounds this. Two further limits concern the evidence base. Conditions attract scholarly attention when they are contested or unusual, so a literature-based study will overrepresent categories such as hwabyeong, which became an object of anthropological and psychiatric debate, and underrepresent categories that are treated without argument. The object of study is also the production and recognition of diagnostic categories rather than patients’ experience of them; the two are related but distinct, and nothing in this design speaks to what living with hwabyeong is like.
These limitations point to future research. The clearest gap is shanghuo, which has almost no anthropological literature despite its everyday prevalence; an ethnography of how excess fire is talked about and treated would show whether the indifference response is as stable as it appears (Pan et al., 2020). A second direction is comparative: applying the three-pathway model to a contested Western condition such as chronic fatigue syndrome, itself linked to neurasthenia, would test it on biomedicine’s own terrain (Ware & Kleinman, 1992). A third is the reflexive question the psychiatric manuals have opened but not pursued: if biomedical diagnoses are themselves cultural prototypes that won acceptance through usefulness, the history of a category like depression can be written with the tools used here for hwabyeong.
Conclusion
Oriental medicine converts biomedically illegible suffering into recognized disease through three mechanisms that can be described and compared, and biomedicine’s answer to the resulting categories follows a pattern of its own. Reading hwabyeong alongside its Chinese counterparts suggests that the same mechanisms may operate inside biomedical classification, though two cases and a reading of psychiatric manuals support that only as a proposal. The principal limitation is the narrow case base, best addressed by applying the model to a contested Western condition. What the framework offers meanwhile is a better question: not whether an illness without disease is real, but how any suffering, in any system, comes to earn the name of disease.
Conflicts of Interest
The author declares no conflicts of interest.
Acknowledgements
The author thanks the mentors who encouraged this line of inquiry.