Cad . Sa úd e Púb lic a, Rio d e Jane iro , 17(4):753- 799, jul-ag o , 2001
For a General Theory of Health: pre l i m i n a ry
epist emological and anthropological not es
Para uma Te o ria G e ral d a Saúd e : ano taç õ e s
e p iste mo ló g ic as e antro p o ló g ic as p re l i m i n a re s
1 In stitu to de Saú de Coletiva , Un i versid ad e Fe d e ra l d a Ba h i a . Ru a Pa d re Feijó 29, 4oa n d a r, S a l va d o r, BA 4 0 1 1 0 - 1 7 0 , Bra s i l .
N aom a r d e Alm eid a Filh o 1
A b s t r a c t In ord er to con d u ct a p re l i m i n a ry eva lu a tion of the con dition s a llow in g for a Ge n e ra l T h e o ry of He a l t h , th e au th or ex p l o res tw o im p ortan t stru ctu ral d im en sion s of th e scien tific h ea lth f i e l d : th e socio-an th ropological dim en sion an d th e ep istem ological d im en sion . As a p re l i m i n a ry sem an tic fra m ew o rk , h e adopts the follow in g d efin ition s in En glish an d Po rtu gu ese for tw o series of m ean in gs: disease = p a t o l o g i a, d i s o rd er = t ra n s t o rn o, illn ess = e n f e rm i d a d e, sick n ess = d o e n ç a, a n d m alad y = m o l é s t i a. He b egin s b y d iscu ssin g som e sociological th eories an d biom ed ical con -cep ts of h ea lth -d isease, w h i c h , desp ite th eir lim it a tion s, can be u sed as a p oin t of d ep art u re for th is u n d ert a k i n g ,g i v en th e d ialectical a n d m u ltid im en sion al n atu re of th e d iseaseilln esssick -n ess com p lex (DIS). Se c o -n d , he p rese-n t s a-n d eva lu a tes som e u -n d erlyi-n g socio-a -n t h ro p o l o g i c a l t heories of d isea se, takin g a dva n ta ge of th e op p ortu n ity to h igh light t he sem eiologic treatm en t of h ealth -d isea se t h rou gh th e th eory of “s i g n s , m e a n i n g s , an d h ea lth p ra c t i c e s”. T h i rd , he an a lyze s s e ve ral epist em ologica l issu es rela tin g to th e Health th em e, seek in g t o ju stify it s st atu s as a scien -tific object. Fi n a l l y, th e au th or focu ses th e d iscu ssion on a prop osal to system atize va riou s h ealth con cepts as an in itial stage for the th eoretical con stru ction of th e Collective Health field .
Key word sEp id em iologic Mo d e l s ;T h e o retical M o d e l s ; Ep idem iologic M e t h o d s
R e s u m o Com o objetivo d e ava liar p relim in arm en te as con d ições de p ossibilid ad e de u m a Te o-ria Ge ral d a Sa ú d e, ex p l o ra -se d u as d a s m a is im p ort a n tes d im en sõ es estru t u ran t es d o ca m p o cien tífico d a saú d e: a d im en sã o sócio- an t rop ológica e a d im en sã o ep ist em ológica. Com o m ar-cação sem ân t ica p re l i m i n a r, p rop õe-se u m a fix ação d e sen tid o em Po rtu gu ês p ara d u a s séries s i g n i f i c a n t e s :d i s e a s e = p a tologia,d i s o rd e r = t ra n s t o r n o,i l l n e s s = en ferm id a d e,s i c k n e s s= d o e n ç a ,m a l a d y= m olést ia . In i c i a l m e n t e , d iscu t e-se algu m as teorias sociológica s e con cep ções b iom édicas de saú de- doen ça qu e, n ão obstan t e su as lim itações, sem d ú vid a p od erão ser tom ad a s com o p on to d e p artid a p a ra este esforço, d ad o o carát er d ialét ico e m u ltid im en sion al d o Com -p l ex o D- E-P (d oen ça -en ferm id ad e--p at ologia ). Em segu n d o lu ga r, a lgu m a s ab ord a gen s sócioa n t rop ológicsócioa s sócioart i c u l sócioa d o rsócioas d e teorisócioa s d e d oen çsócioa são sócioa p resen tsócioa d sócioas e sócioavsócioa l i sócioa d sócioa s , sócioa p rove i t sócioa n d o -se a op ortu n idad e p a ra d esta ca r u m tra tam en to -sem iológico d a saú d e-d oen ça , a t rav és d a teoria d os “s i g n o s , sign ificad os e p rát icas d e saú d e”. Em t erc e i ro lu gar, an a lisa m -se algu m a s q u estões ep istem ológicas em torn o d o tem a Saú d e, b u scan d o ju stifica r o seu estatu to de objeto cien tífico. Fi n a l m e n t e , coloca- se em d iscu ssã o u m a p rop osta d e sist em a tiza çã o d e d ist in t os con ceitos d e s a ú d e , com o etap a in icial p ara a con stru ção teórica d o ca m po da Saú d e Coletiva .
I n t ro d u c t i o n
In th e va r iou s d iscip lin es c om p r isin g t h e so-c alled h ealth field , we ob ser ve tim id attem p ts a t co n c ep tu a lly con str u ct in g th e “ h e a l t h” ob -ject (Cze resn ia, 1999: Levin e, 1995), in con tra s t with t h e ext en sive e ffor t s at d eve lop in g b io-m edical disease io-m odels (Abed, 1993; Be r l i n g u e r, 1988; Mu r p h y, 1965; Pére z - Ta m a yo, 1988; Tem kin , 1963), em p h asizin g the in dividual an d sub -in d ividu al levels of an alysis.
In ord er t o con d u c t a p re l i m i n a r y a ssess-m en t o f th e con d ition s a llowin g for a Ge n e ra l T h e o r y of Health, I p rop ose herewith to exp lore t wo im p or tan t u n d erlyin g d im e n sion s in th e scien tific field of h ea lth : th e soc io -an th r o p o-logica l d im en sion an d th e ep istem olo gical d i-m en sio n . Th e ep id e i-m iolo gic al d ii-m en sion o f th e h ealth con cep t wa s th e object of a sp ecific p ap er (Alm eida Fi l h o, in p ress). Desp ite re c o g-n izig-n g its im p or t ag-n ce ag-n d fou g-n d ig-n g ro l e, th e b iologic al dim en sion will n ot b e cove red here, e xc ep t in sofa r as it p rove s in d isp e n sa b le t o c l a rify som e sp ecific issu e in th e health-disease m od els an alyzed h erein . Asp ects p ertain in g to t h e e tym olo gy of th e ter m “ h e a l t h” we r e th e object of a related article (Alm eid a Fi l h o, 2000). First, I in ten d to d iscu ss som e sociolo gical t h e o r ies of d isea se- illn ess-sickn e ss a n d b io-m edical con cep ts of h ealth , wh ich, desp ite th e lim itation s d iscu ssed b elow, ca n d ou b tless b e taken as the p oin t of d ep art u re for this u n d erta kin g, given t he d ia lect ical an d m u ltid im en -sion al n atu re of th e h ealth -d isease d yad . Se c-on d , I will p resen t an d assess seve ral u n d erly-in g socio-an throp ological ap p roach es to theo-r ies of d isease, takin g ad van tage of th e op p otheo-r- or-t u n ior-t y or-t o h igh ligh or-t or-th e sem eiologic or-tre a or-t m e n or-t of health -d isease through th e th eor y of “s i g n s, m e a n i n g s, a n d h ea lth p ra c t i c e s”. T h i rd , I will a n a l y ze seve ral ep istem ological issues p ert a i n -in g to th e h e alt h t h em e, seek-in g to ju stify it s statu s as a scien tific ob ject. Fi n a l l y, I in ten d to fo cus th e d iscu ssio n on a p ro p osal to system -a t i ze v-a r iou s c on c ep ts of h e-alth -a s t h e in iti-al sta ge fo r th eir a p p lica tion to the th eo re t i c a l c o n s t ru ction of the Co l l e c t i ve Health field.
Be f o re enterin g in to the discu ssion, I s h o u l d p rovid e a p re l i m i n a r y sem an t ic fra m e w o rk . The En glish lan gu a ge, th e m a trix for th is sp e-c ifie-c lit er a t u re, m akes su b tle d istin e-ct ion s in m ean in g b etween th e va rious con cep ts of d is-ease an d related ter m s, th rou gh two sem an tic s e ries: disease-disord e r- i l l n e s s - s i c k n e s s - m a l a-d y an a-d im p airm e n t - a-d i s a b i l i t y- h a n a-d i c a p. T h e s e two serie s refer to a p a rticu la r te chn ica l glo s-s a r y, wh ich d u e to its-s gr owin g im p o rta n c e in c o n t e m p o ra r y sc ie n t ific d iscou rse d eser ve s
Cad. Saúde Púb lica , Rio de Jane iro , 17(4):753-799, jul-ag o , 2001
so m e a tt en tion in th e se n se of esta b lishin g a t e rm in olo gica l e q u iva len ce in Po rt u g u e s e, a s in disp en sab le b ackgrou n d for p articip ation by Brazilian re s e a rchers in th is deb ate. T h u s, eve n wh ile re co gn izin g th at su c h a tt em p t s c an b e a r b i t ra r y a n d in co m p le te, I p rop ose t o ad op t th e followin g term i n o l o g y, wh ich I will ad here to strictly th rough ou t the rest of this p ap er : • d isease = p a t o l o g i a,
• d i s o rder = t ra n s t o r n o, • illn ess = e n f e r m i d a d e, • sickn ess = d o e n ç a, • m alady = m o l é s t i a.
The irony of social theories of health
In the field of social scien ces ap p lied to health, sin c e World War II th ere h as b een a som ewh at in sisten t searc h to o b jectively d efin e th e c on -ce p t of d isea se an d its co rrela te s (Hu m b er & A l m e d e r, 1997), with a view tow a rd s form u l a t-in g “so cial theor ies of h ealth”. Th is section re-view s som e of th ese p ro p o s a l s, ori g i n a t i n g m ain ly from An glo-Sa xon Medical So c i o l o g y.
Talcott Pa r s o n s, whose work ascr ib es an es-p ec ially cen tr al ro le to h ealth es-p hen o m en a fo r an un d erstan din g of th e social system , d efin ed illn ess as a “sta te of d istu rban ce in th e n orm al fu n ction in g of th e t ot al h u m an in d ividu a l in -clu d in g t h e organ ism as a biological system as m u ch a s its p erson al an d socia l ad ju stm en t” ( Pa rso n s 1951:431). Pa r s o n’s th eo ry of th e sick role is th e first con ceptual re f e ren ce to a seri e s of defin ition s of the sickn ess con cep t as a soci-etal com p on en t of th e disease-illn ess com plex, as we will see fu r th er o n . Cu ri o u s l y, Pa r s o n s does n ot highligh t th e term d i s e a s ein h is the o-ry, rath er u sin g illn ess an d d i s o rd e r, even when it is n ecessa ry to refer t o th e ob jective p ath o -logical asp ects of disease (Pa r s o n s, 1951, 1964, 1 9 7 5 ) .
Th e au thor later prop osed to an alyze He a l t h as a social fun ction , defin in g it as a “state of op -tim u m ca pacity for th e effective p erform an ce of (socially) valu ed tasks” (Pa r s o n s, 1964). Pa r s o n -ian fun ction alist th eor y served as the theore t i-cal m atrix for app roach in g in d ividual health as a social ro l e, p erf o rm a n c e, fun ction in g, activi-t y, an d cap aciactivi-ty, a m on g oactivi-th er s, wh ic h we re su b seq u e n tly c o n d en sed in the c on c ep t of h ealth as social well-b ein g, a c h ara c t e ristic of c o n t e m p o ra r y “qu ality of life” rh e t o ri c.
Cad . Sa úd e Púb lic a, Rio d e Jane iro , 17(4):753- 799, jul-ag o , 2001 c om m o n sen se. As en t r ie s in th e tr a d i t i o n a l
O x f o rd Di c t i o n a r y (1968), d i s e a s e m ean s “a con d ition of the bod y, or of som e p art or organ of the bod y, in w h ich its fu n ction s are dist u rbed or d era n g e d”an d illn ess is sim p ly d efin ed as a “q u ality or con d ition of b ein g ill (in va r i o u s s e n s e s )”.
Fie ld (1976) c on ce p tu a lized d ise ase as a n a b n o rm ality or p ath o lo gical alter ation re c o g-n i zed by m eag-n s of a set of sigg-n s ag-n d sym ptom s d efin e d on th e b a sis o f a b iom ed ic al con cep -tion . On t h e oth er h an d , illn e ss re f e r red p rm a rily to the su bjective exp erien ce of an in d i-v i d u a l’s st ate o f “ill h ealt h”, in d icated b y f e e l-i n g sof p a in , d isc o m for t , a n d m ala ise. Pa y i n g t rib ute to the Parson ian theory of the sick ro l e, but without usin g the termsickn ess, Field ( 1 9 7 6 ) f u rth er con te n d ed th at illn e ss d id n ot sim p ly im p ly a “b iologica lly altered state”, b u t also to b e in a soc ia lly a ltered sta te wh ich is see n as both devian t an d (n orm ally) u n d esira b l e.
In h is sem in al work Cau sa l Thin kin g in th e Health Scien ces, Me rvyn Susser (1973) p re s e n t -ed two series of defin ition s that con tribu t-ed lit-tle to ove rcom in g th e term in ological con fusion then p re vailin g, p robab ly b ecau se of th e lim it-ed d iffu sion of h is writin gs ou tsid e o f th e ep i-dem iological field. Accordin g to Susser, the t e rm d isease refers to a p ath op h ysiologic al p ro c e s s th at cau ses a state of p hysiological or p syc h o -logic al d ysfun ction in th e in d ivid u al. On th e oth er h an d , illn ess is an in divid u al, sub jective s t a t e, a c erta in p sych ologic al an d c or p ora l a w a ren ess o f t h e d isease, wh ile sickn e ss im -p lies a st at e of soc ial d ysfu n ct io n in th e sick sub ject, cor respon d in g to Pa r s o n s’ sick ro l e.
Philosop her Ch ristop her Boorse (1975, 1 9 7 7 ) defin ed d isease as an in tern al state of the b od y resu ltin g from sub n or m al fu n ction in g of som e of its o rga n s or su b - syste m s. Som e su c h d is-eases can evo l ve to illn ess if they lead to lim ita-tion s or d isabilities that m eet th e followin g crit e ria: (i) critha crit crith e y b e u n d esira b le fo r crith e su b ject; (ii) th at th ey b e con sidered eligib le for in -t e rven -tion s; (iii) -tha-t -they con s-ti-tu-te a ju s-tifica- stifica-tion fo r n or m ally re p ro ach a b le socia l b e h a v-i o r s. Desp v-ite the clear fu n ctv-ion alv-ist v-in spv-ira t v-i o n (alon g the Du rk h e i m - Parson s lin eage), there is n o sp ecial p osition in Bo o r s e’s origin al pro p o s-al fo r th e t erm s i c k n e s s, wh ile illn ess con sti-tu tes a m er e sub se t in t he or d er of d ise ases, n am ely t h ose th a t p ro du ce p sych ologic al an d social con sequ en ces for th e in d ivid ual.
Bo orse sub seq u en t ly stat ed h is in te n t (1977) “to offer a va l u e - f ree an alysis” as the ba-sis fo r a t h e ore tic al con c ep t of He alt h, a lon g th e sam e lin es as th e b iological con cep ts of life an d death (am on gst us Bra z i l i a n s, the p ion
eer-in g wo rk of Már io Ch aves (1972) h ad alre a d y c o n c e p t u a l i zed h ealth as an org a n i s m’s capaci-t y capaci-to fu n ccapaci-t io n wicapaci-t h in an e co syscapaci-te m re s u l capaci-t i n g f rom t h e Ero s-Tha n a tos o p p o sit ion , in lin e o f t ho u ght in trigu in gly sim ilar to Bo o r s e’s p r o-p osa l). Boo rse o-p ro o-p osed a lin ear a rt i c u l a t i o n i n volvin g four basic con cep ts: “re f e ren ce class”, “n o rm al fun ction”, “d i s e a s e”, an d “ h e a l t h”. T h e re f e ren ce class con sists of the un iverse of m e m -b ers of a -biological species of the sam e sex an d age b ra cke t. No rm al fu n c tion is d efin ed a s an in d ivid u al con t r ib u tion t ha t is “s t a t i s t i c a l l y t y p i c a l” in relation to th e re f e ren ce class for th e s p e c i e s’ su rv i val an d re p rod uction . Disease is a redu ction in the “typ ical efficien cy” in vo l ved in n o rm al fu n ction . Health m ean s sim p ly th e ab-sen ce of disease. Boorse com p letes his “ b i o s t a-t isa-tic a l a-t h e or y o f h ea la-th” wia-th an in a-ten a-t io n al t a u t o l o g y, in d ica tin g t h a t hea lth a s a co n cep t ca n sim p ly im p ly n or m a l i t y, always “in th e sen se of th e absen ce of disease con dition s”.
Co n t ra r y to th e n a tu ra list th eo re t i c i a n s (m a in ly Boor se ) wh o b elieved in an ob ject ive a n d va l u e - f ree ap p roa ch to h e alt h- d ise ase p hen om en a, Tristh am En g e l h a rdt (1975) iden -tified a fallacy in th is op eration of con sid eri n g a b s t ract con stru cts as con crete th in gs an d pref e r red to trea t t h e m as d iprefpreferen tiat ed a n d a u ton om ous en tities. T h u s, h e ju stified the d efin -ition of d i s e a s eas a scien tific category d estin ed to e xp lain an d p red ic t illn ess, su ggestin g tha t t h e latt er, an d n ot d isease, was a re f e r en t for h ea lth p h en om en a . In h is own wo rd s (En g e l-h a rd t, 1975:137): “Com m itm en t to the con cep t of d isea se p resu p p oses th at th ere are p hen om e-n a ph ysical ae-n d m ee-n tal w hich cae-n be corre l a t e d w ith even ts of p ain an d su fferin g, so th at th eir pattern s can be ex p l a i n e d , th eir cou rses pre d i c t-e d , an d th t-eir ou tcom t-es in flu t-en ct-ed favo ra b l y”.
Ph en om en o logic al ap p ro ach e s to h e alt h ( En g e l h a rd t, 1975) we re cr itical of n a tu ra l i s t t h e o ri e s’ ob jectivism . Re c e n t l y, su ch cr i t i c i s m reach ed th e extrem e of ch allen gin g th e u sefu l-n e ss of t h e ve r y c ol-n c ep t of d ise ase (He s s l ow, 1993), a p p a ren t ly with n o e ch o am o n g re-s e a rch erre-s in vo l ved in th e im p o rta n t effort at t h e o retical con stru ction of th e field of Me d i c a l So c i o l o g y.
Cad . Saúd e Púb lic a, Rio d e Jane iro , 17(4):753-799, jul-ag o , 2001
p rocesses th at we re d ifficu lt to classify as sick-n ess or d isease, su ch as d isord e r, d ysfu sick-n ctiosick-n , d e p e n d e n c y, d efec t, le sion , t rau m a, etc . Desp ite th e p ro p o s a l’s p roper in ten tion s, the con -cep t of m a l a d yh as n ot been in corp orated in to eith er th e th eoretical discou rse of th e So c i o l o-gy of Health or th e tech n ical d iscourse of Clin ical Me d i c i n e, an d is m ostly re f e r red to as a cu -riosity in d icatin g the in su fficien cy o f th e d is-ease con cep t.
Th e Pörn - No rd en feld th eo ry (Pö r n , 1984, 1993; No rd en feld , 1987, 1993), d evelo p e d as p a r t o f an effor t a t an ec on o m ic an d p h ilosop h ic al ju stifica tion fo r Sc a n d in a via n “n e o -we l f a ri s m”, was in ten ded to re c over a p ra g m a t-ic d efin ition o f h ea lth b ased on up d atin g an d c o r rectin g Bo o r s e’s biostatistical ap proach. De-sp ite th e co n c ep t ua l lim ita tion s an d even a c e r tain p h ilo sop h ica l n aiveté in t h is form u l a -t ion , -th e p r op o sal by Pö rn (1984) is ce r-t a i n l y i n t e restin g, i.e., th at the sym m etrical op p osite of h ea lth is n eit h e r d isease n or sickn ess, b u t r at h e r illn e ss (Pör n , 1984). In o th er wo rd s, h ea lth is n ot th e ob jective a b sen ce of disease, b u t t h e n o n existen c e o f illn ess in t er m s o f a d ap ta tion of a hu m an organ ism to a b io lo gi-cal an d social en viron m en t (Pörn , 1993).
Presen tin g a ve r y we l l - s t ru c t u red th eore t i-ca l fo rm u la tion wh ich h e en t itle d t he “p h e-n om ee-n ology of health”, No rdee-n feld (1987) p ro-p osed a distin ction b etween objective an d su b-j e c t i ve illn ess wh ich , as a logical con sequ en ce of Pörn’s health-illn ess con tin u um , leads to th e m i r ror con cep t of “s u b j e c t i ve h ealth”. Objective illn ess is defin ed by th e poten tial fun ction al ca-p acity n ot affected by th e cau se of th e disease, while ob jective health corresp on ds to the actual exerc ise of th is fun ction actual ca p acity. Ac c o rd in g t o t his sch em e, sub jective illn ess (or n on -h ealt-h ) -has two com p on en ts: (i) t-h e aware n e s s of illn ess (in th e a u thor’s word s, th e “m e re be-lief or a ware n e ss th at so m eo n e is ill”) an d (ii) t h e fe elin g of illn ess (o r th e “set of m en t al states associated with illn ess”). T h u s, as p ostu-lated by No rden feld , a p erson P is sub jective l y h ealth y if a n d on ly if h e/ sh e (1) is n ot su b jec-t i ve ly ill, (2) b elieves jec-th ajec-t h e/ sh e is h ealjec-th y, or (3) is n ot exp erien cin g a m en tal state associat-e d wit h som associat-e c u rrassociat-e n tly associat-existin g ob jassociat-ec tivassociat-e ill-n ess (No rd eill-n feld, 1987, 1993).
Alon g th is sam e lin e, Fu l f o rd (1994) c on -t en d s -th a-t n o-t e ven -th e con cep -t o f d ise ase is va l u e - f re e, d efen d in g a p ra gm atic a p p ro a c h t h rough th e u se of two d ifferen t levels of an aly-s i aly-s, on e d ealy-scr i p t i ve an d th e o th er in terp re t a-t i ve. Gi ve n a-t ha a-t a-th e fo rm e r le ve l in co rp o ra a-t e s disease con cep ts in which a h igh degree of c o n -sen su s p re va i l s, accord in g to Fu l f o rd it is n
ec-e s s a r y to focu s m o rec-e o n th ec-e lattec-e r an alyt ica l l e vel. In this case, disease con cepts could be re-f e r red to gen er ically as “re-f a i l u re s”. Disease w o u l d c o r resp o n d t o a “ro le fa ilu re”, wh ile illn e ss wou ld result fr o m an “act io n failur e”. Fi n a l l y, Fu l f o rd (1994) challen ges th e existen ce of a de-t e rm in isde-tic lin k b ede-tween disease an d illn ess, as p o st u lated by th e m ajor ity o f th e au t h o rs re -v i e wed , in dicatin g th at th e actu al illn ess exp er ie n ce ca n n ot b e exp lain ed b y d isea se co n -c e p t s, th at rat h e r it m u st b e un d erst oo d as p h en om en ologically give n .
Re c e n t l y, Boo rse (1997) selfc rit ically ad -m itted th e n eed to ove rco-m e his n egative - e vo-l u t i ve con cep t of heavo-lth (b ased on th e dysfu n c-tion -d isease-illn ess gradien t), p roposin g to re-p lac e it with th e n otion of “d e g rees of h ealth”. Th is en tails a n extrem ely n arr ow d efin ition of p o s i t i ve h e alt h as th e m axim u m p o ssib le d e -g ree o f h e alth as o p p osed to an y red u ctio n in op tim u m n or m al fu n ct io n for th e re f e re n c e c l a s s. Ac c o rdin g to this con cep t, n orm ality h as t h ree levels of sp ecificatio n : th eoretically n or -m al, d iagn ostically n or-m al, an d th era p e u t i c a l-ly n or m a l. Th e logical op p osite o f th e d isease co n c ep t wou ld b e th e ore tical (o r c on ce p tu al) n o rm a l i t y. Th e re s p e c t i ve an tagon ists would fit with the oth er levels of n orm a l i t y: diagn ostical-ly ab n orm al an d th erap euticalostical-ly abn orm al. Fi-n a l l y, Boorse aFi-n alyzes th e extrem e situ atioFi-n s of “ i l l n e s s” (as op posed to “we l l n e s s”) an d d eath -l i f e. Th e u n d er-lyin g re-lation sh ip s of be-lon gin g an d op p osition in this in t erestin g sch em e are foun d in Fi g u re 1. Cu riou sly en ough , the essen -tial fra m e w o rk of this p roposal h ad also alre a d y b een la id ou t in t h e stud y b y Má rio Ch a ve s (1972) quoted above.
Cad . Saúde Púb lic a, Rio d e Jane iro , 17(4):753-799, jul-ag o , 2001 A n t h ropological models
of disease-illness-sickness
Th is sect ion exp o un d s on th e issu e o f h ealth -d isea se m o -d els fr om th e in ter p re t a t i ve p er-s p e c t i ve of con tem p ora ry Medical An thro p o l o-g y, con ve ro-gin o-g o n a p ro p osa l in teo-gratin o-g th e con cepts of disease, illn ess, an d sickn ess.
A rth ur Klein m a n , Leon Ei s e n b e rg, an d By-ron Good (Klein m a n et al., 1978), seekin g to e n rich t he a n alysis o f n on - b iologic al com p on eon ts of h ea lth d isea se p h eon o m e on a, system -a t i ze d in 1978 -a m od el th -at -ascr ib e d sp eci-a l t h e o re tical im p ort an ce to th e n o tion of “s i c k-n e s s”, em p h asizik-n g th e social a k-n d c u ltu ra l a s-p ects th at ha d s-p ara d oxic ally b een ove r l o o k e d by p reviou s sociological app ro a c h e s. (Cu ri o u s-l y, Ks-lein m a n an d h is d iscip s-le s o m itt ed p r i o r c on c ep tu a l d eve l o p m e n t s, e ve n tho se occu r-rin g with in th e field of social scien ces in h ealth as discussed in th e p reviou s section ). This p ro-p osal was based on the d istin ction between bi-olo gical a n d cu ltu ra l d im en sio n s o f sic kn e ss, c o r resp on d in g to two ca tego rie s: d isea se an d i l l n e s s. Th e m od el is shown sc h em atic ally in Fi g u re 2, h igh ligh tin g t h e im p licitly n egative defin ition of h ealth as the ab sen ce of sickn ess.
Fro m th is p e r sp ec tive, t he p a th olo gica l fun ction in g of organ s or p h ysiological system s occu rs re g a rdless of its recogn ition o r p erc e p-tion b y th e in d ivid u al or soc ial en vir o n m e n t . Wit hin a fram e of re f e r en ce t h at is qu it e co n g ruen t with Bo o r s e’s theor y, accordin g to Klein -m an (Klein -m an , 1980, 1986; Klein -m a n e t a l., 1978), d isease refers to alteration s or d ysfu n c-tion in biological an d/ or psychological p ro c e s s-e s, a s d s-efin s-ed b y th s-e b iom s-ed ic al c o n cs-ep t. On th e oth er ha n d , th e illn e ss ca tegor y in co rp o -rates in dividu al exp erien ce an d p ercep tion và-vis b oth th e p roblem s d erivin g from th e d is-ea se a n d so cia l r is-eact io n t ow a rd s illn e ss. T h e co n ce p t o f illn ess th u s re late s to p roce sses of sign ifyin g sickn ess. In ad dition to th eir cultura l asp ects, m ean in gs also touch on p articular s y m -b o lic asp ects for m in g t h e illn ess itself with in th e in divid u al p sych ologica l sp h ere, as well as th e m ea n in gs c rea te d by t h e p a tien t wh ile dealin g with th e disease p rocess (Massé, 1995). Su b s e q u e n t l y, Klein m an (1988, 1992) p a r -tially re v i e wed his or igin al objectivist p osition , c on te n d in g th at b ot h d ise ase an d illn e ss are so cia l c on stru c t s. Illn ess m e an s th e way sick in d ivid uals p erc e i ve, exp re s s, an d d eal with th e p rocess of becom in g ill. Illn ess is th u s p rior to s i c k n e s s, wh ich is p ro d u ce d o n th e b asis o f a te ch n ic al re c o n s t r u c tion of p r ofession al d is-cou rse in t he p h ysician - p a tie n t en is-cou n ter, t h rou gh com m un ication arou n d th e cu ltu ra l l y
s h a red lan gu a ge of sic kn ess. Ac c o rd in g to th is sam e au th or (Klein m an , 1980), h ealth, illn ess, a n d ca re are p a rts of a cu ltu ral syst em , an d a s su ch they shou ld b e un derstood through th eir m u tual re l a t i o n s. To exa m in e th em sep ara t e l y d i s t o r ts o u r u n d erstan d in g of b ot h t h eir re-s p e c t i ve ch ara c t e rire-sticre-s an d the way th ey fun c-tion in a given con text.
Klein m an (1986) fu rth er p rop osed th at on e of th e reason s th at differen t h ealin g p ro c e s s e s p ersist with in th e sam e society is becau se they act on d ifferen t dim en sion s of sickn ess. T h u s, on e m u st con sider differen t m od els cap able of con ceivin g h ealth an d illn ess as resu ltin g fro m t h e c om p lex in t eraction am o n g m u ltip le fa c-tors at th e biological, p sych ological, an d socio-logical leve l s, with a term in ology n ot lim ited to b i o m e d i c i n e. In o rder to c on stru ct such m od -e l s, on -e m u st tur n to n -ew in t-erd i s c i p l i n a ry
D e a t h
S i c k n e s s
The rap e utic ab no rm a l i t y The rap e utic no rm a l i t y Diag no se d ab no rm a l i t y Diag no se d no rm a l i t y
T h e o re tic al no rm a l i t y D i s e a s e
Po sitive he alth Sub -o ptimal he alth
We l l n e s s
L i f e F i g u re 1
B o o r s e ’s d e g re e s o f he alth mo de l.
Sickness: disease + illness
d i s e a s e
H E A LT H S I C K N E S S
i l l n e s s F i g u re 2
Cad. Saúde Púb lica , Rio de Jane iro , 17(4):753-799, jul-ag o , 2001
m e t h o d s, workin g sim u ltan eously with ethn o-g rap h ic, c lin ic al, ep id e m ioloo-gical, h isto ri c a l , social, p olitical, econ om ic, tech n ological, an d p s ychological data.
By r on Goo d & Ma r y- Jo Goo d (1980, 1982), re i n f o rcin g th e p ersp ective of in tra- an d in ter-c u l t u ra l rela tivism in illn e ss, p o st u la ted t h at th e b ord ers between n orm al/ p ath ologic al an d h ealth/ d isease are estab lish ed by illn ess exp e-rien ces in d ifferen t cu ltu re s, th rou gh the ways by wh ich th ey a re n a rrate d , an d by th e ri t u a l s e m p l oyed to re c o n s t ru ct the world that su ffer-in g d estroy s. From th is p er sp e ct ive, sickn ess (an d b y exte n sio n , h ealth ) is n o t a th in g in it-self, or even a re p resen ta tion of su ch a th in g, b u t an o b jec t resu lt in g fro m th is in te ra c t i o n , cap able of syn th esizin g m ultip le m ean in gs.
Go od & Goo d (1980) p ro p ose d a “c u l t u ra l h erm en eu tic m o del” to u n d erst an d We s t e rn m ed ical ra t i o n a l i t y. Ac c o rdin g to these au thors, the in terp retation of sym p tom s as a m an ifesta-t io n of ifesta-th e u n d er lyin g “b io logical realiifesta-t y” is c h a ra c t e r istic of clin ic a l rea son in g, sin ce th e latter is based ep istem ologically on an em p iri-c ist t h e or y of lan gua ge (Go od & Goo d , 1980). Ac c o rd in g t o th e b iom ed ical h e alt h -d ise ase m odel, clin ical p ractice is sup p orted by kn ow l-ed ge of causal ch ain s op eratin g at th e b iologi-cal level, followin g a scrip t for decodin g the p at i e n at’s co m p lain at s in ord e r ato id en atify at h e u n -d erlyin g som atic or p sych ological p ath ological p ro c e s s. T h u s, th e m o d el h as a d o u b le ob je c-t i ve: c-to e sc-tab lish c-t h e d ise ase d iagn osis a n d c-t o p ro p ose e ffective an d rat ion a l tre atm en t. Ac-c o rd in g t o Goo d & Goo d (1982), asAc-cr i b i n g “sym p tom m ean in g” to an a ltered p h ysiologcal state p roves in su fficien t as a b asis for clin i-c al p ra i-c t i i-c e, sin i-c e p syi-ch olo gii-ca l, soi-cia l, an d c u l t u ra l fa ct or s in flu en ce th e exp e r ien ce of s i c k n e s s, its m an ifestation , an d th e exp re s s i o n of sym p tom s.
On e of the cen tral p oin ts in th is “c ritical re-f o rm ” p ro c ess in m e d ic a l kn owled ge co n sist s of th e d istin ction between d isease an d illn ess. A g reein g with Klein m an , Good & Good (1982) re a f f i rm that the disease process correlates w i t h or is cau sed by biological an d/ or p syc h o l o g i c a l a l t e ra t i o n s, wh ile illn ess is situ ate d in th e d o-m ain o f lan gu age a n d o-m ea n in g a n d t he re f o re c on stitu tes a h um an exp eri e n c e. Ac c o rd in g to th ese auth ors, illn ess is fu n d am en tally sem an -t ic, an d -th e -tr a n s f o rm a-t io n of d isea se in -t o a h um an experien ce an d an ob ject of m edical at-ten tion occurs through a p rocess of attri b u t i o n of m ean in g. T h u s, n ot on ly illn ess b ut also d is-ease con stitu te a cu ltu ral con struct, in th is case b ased on th eory an d webs of sign ifican ce com -p r isin g th e differen t m edical sub -cultu re s.
Mean in g is n ot the p rodu ct of a closed re l a-tion ship between sign ifier an d th e thin g (in the sen se of an objective reality in th e physical u n i-verse), b ut of a n etwo rk of sym b ols con stru c t-ed in th e in terp re t a t i ve act, wh ich th ey refer to as a “sem an tic n etwork” (Good & Good , 1982). Illn ess b ecom es an e xp e r ie n ce wit h m ea n in g for each p articu lar in d ivid ual. Even so, it is im -p o rta n t to con sid er th e rela tion sh i-p b e twe e n in d ividu al m ean in gs an d th e n etwork of m ean -in gs -in h eren t to each broad er cu ltu ral con text to wh ich in d ivid ua ls b elon g. T h e re in lies t h e n otion of illn ess as a “n e t w o rk of sign ifican ce”, in th e sen se of a rea lity con stru cted th rou gh a p rocess o f in t erp retation / sign ificat ion , b ased on the p lot of m ean in gs that str u c t u res the cult u re icultself an d icults va r iou s su b culculture s. Sy m p -t o m s, fu ll of a-t leas-t in divid ual m ean in gs, allow ac cess t o b iom ed icin e’s web of sign ifica n ce, tha t is, cu ltu ra lly estab lish e d d isease sign s in th e form of a “s y n d rom e of m ean in gs” (Good & Good, 1980).
In a n atte m p t to d evelo p a n a p p r oac h to the determ in ation of sickn ess in societies b a s e d on an alysis o f social re lat io n s o f p ro d u c t i o n , Allan You n g (1980, 1982) p resen ts a critiq u e of sickn ess m od els as p rop osed by Klein m an an d Good & Good . On the on e h an d , he p o stu lates th at th e Kle in m an -Goo d m od e l on ly see s th e in d ivid u a l as o b jec t a n d a ren a for sign ifican t e ven ts re g a rd in g illn ess, fa ilin g t o re p o rt t h e ways b y wh ic h social relation s form a n d d is-t rib u is-t e iis-t. On is-th e o is-th er h an d , wh ile a ckn ow l-ed gin g t he Klein m an -Goo d m od el’s ad va n c e s over the b iom ed ical m o d el, You n g con t en d s th at the d istin ction between d isease an d illn ess is in su fficien t to exp lain th e social d im en sion s of th e p rocess of becom in g ill.
To ove rcom e these lim itation s, Youn g ( 1 9 8 0 ) p rop oses to rep lace the Klein m an -Good s c h e m e [sickn ess = disease + illn ess] with a trip le seri e s of c a tegor ies (sickn ess, illn ess, an d d ise ase) with eq uivalen t h iera rchical leve l s, albeit g ra n t-in g gre at er th eor etica l re l e van c e to th e “s i c k-n e s s” com p ok-n ek-n t. It is ik-n th is sek-n se th at Yo u k-n g en d s u p p ostu latin g an “a n t h rop ology of sick-n e s s” (You sick-n g, 1982). He reisick-n , I p rop ose to designate the You ng m odel as DIS Com p lex (dise a s e -illn ess- sickn ess), as re p resen ted in Fi g u re 3.
Cad . Sa úd e Púb lic a, Rio d e Jane iro , 17(4):753-799, jul-ag o , 2001 illn ess an d tre a t m e n t s, as well as th eir co n
se-q u e n c e s. T h e re f o re, th e e lem en ts of th e DIS Com p le x (d isea se -illn ess- sickn ess) co m p le x a re n ot n eutral term s, b ut rath er en tail a circ u -lar p rocess by which b iological an d beh aviora l sign s are socially sign ified as sym p tom s. T h e s e s y m p t o m s, in tu r n , are in terp reted by way of a se m eiolo gy th at a ssoc ia tes t h em with cer t a i n etiologies an d th at justify in ter ven tion s wh ose resu lts en d u p legitim atin g th em as diagn ostic sign s of c ert ain d iseases. Th e au th or fu r t h e r com m en ts th at in p lu ralistic m ed ical system s, a set o f sign s c an d esign a te d ifferen t illn esses an d th erap eu tic p rac tices th at fa il to ove r l a p. Soc ia l for ces a re wh at d et erm in e wh ic h in d i-vid u als suffer cer tain illn esses, disp lay cert a i n s i c k n e s s e s, an d ha ve a c ce ss to given tr e a t-m e n t s. Dep en d in g on th e sick in d ivid u al’s so-c ioeso-co n om iso-c p osit ion , th e sam e d isea se so-ca n im p ly d iffere n t illn e sses an d sickn esses a n d d i f f e ren t healin g p ro c e s s e s.
Ac c o rd in g to Yo u n g (1980, 1982), the co n -cep t of sickn ess should in corp orate the p ro c e s s of a scr ib in g socially ac kn owled ge d m ean in gs to sign s of devian t behaviors an d biological sig-n a l s, tra sig-n s f o r m isig-n g th e m isig-n to socia lly sigsig-n ifi-ca n t sym p to m s an d eve n t s. In h is own word s, “Sickn ess is a process for socializin g disease an d i l l n e s s” ( Yo u n g, 1982:270). Th is p roc ess of socializin g disease – or b etter still, of social con -s t r uc tion o f -sickn e -s-s – o cc u r -s in p ar t within an d th ro u gh m ed ical syst em s, lin ke d to soci-e t y ’s b road soci-er id soci-eologic al circ u i t s. You n g sta tsoci-es th at th is ideological dim en sion , th rou gh differ-en t form s of h ealth kn owled ge an d p ra c t i c e, re-p rodu ces sre-pecific views of th e social order an d acts to m ain tain th e m . In th e fin al an a lysis, re p resen tation s of sickn ess con stitu te elem en ts in the m ystification of its social origin an d social con d ition s in the p rod uction of kn ow l e d g e. Ac-cordin g to Youn g (1980), the tran slation of form s of su ffer in g (illn e ss) d eri ve d fro m c la ss re l tion s in m edical term s con stitutes a n eutra l i z a-tion p rocess followin g the in terests of th e h ege-m on ic classes. That is, through the ege-m edicaliza-tion p ro c e s s, the ill con diedicaliza-tion is red uced to th e in d ivid ua l b iological leve l, failin g to c on sid er its social, p olitical, an d histor ical d im en sion s.
In deed, the focu s on sickn ess su p plan ts the em p hasis on the in dividual or m icro-social lev-els (c hara c t e r istic of Klein m an’s ap p roa ch , for exam p le). Howe ve r, alth ough it is an im p ort a n t step forw a rd over its p re d e c e s s o r s, Yo u n g’s DIS Com p lex op en s on ly on e p ossib ility for in cor-p o ratin g the Health issu e: on ce again the m ere absen ce of disease-illn ess-sickn ess.
In co n clu sion , o n e sh o u ld valu e th e effor t at d raftin g a gen era l theory of h ealth d isea se
-c a re, a b adge of the in telle-ctu al un dertakin g of t h ese d ist in gu ish ed h eir s to th e a p p lie d an -t h rop ology of -the 1970s. Even con sid er in g -the i m p o r tan ce ascr ib ed t o p atien ts’ b eliefs a n d c u l t u ral an d p erson al m ean in gs, a s well as th e p rop osal for in tegratin g va rious com p on en ts of h ea lth care syste m s a n d th eir re s p e c t i ve ex-p l a n a t o r y m od els, th e view o f t h ese t heo re t i-cian s tow a rds th e con ceptual issue of Health is n ot sufficien tly tra n s d i s c i p l i n a ry to broaden th e scop e of th e m ed ical an throp ological app ro a c h , re s t ricted to the view of Health as ab sen ce of ill-n e s s. The Kleiill-n m aill-n-Good aill-n d Youill-ng m odels ac-tually rem ain con strain ed to cura t i ve pra c t i c e s, focu sin g on the ill in d ividual’s re t u rn to n orm a l fun ction in g an d health y life, with ou t even en -t e rin g in -to -the defin i-tion of norm ali-ty or ac-tu al-ly an aal-lyzin g if th e Health con cep t fits in to it.
Semeiologic approaches to health-disease-care
Re c e n t l y, Good (1994) d evelop ed a crit ical sem eiologic persp ective for th e an alysis of h e a l t h -d isease m o-d els, re e valu atin g th e sem an tic n et-w o rk con cep t, iden tifyin g tet-wo lim itation s to it:
Th e first re lat es t o th e red efin it io n o f th e DIS Com p lex in ligh t of lin gu istic th eory, give n th e in sufficien cy of th e p ersp ec tive acc ord i n g to wh ich a sym b ol c on d en ses m u lt ip le m ean -i n g s. Ac c o rd -in g to Goo d , on e m ust r e c o g n -i ze th e diversity of n ation al, e th n ic, re l i g i o u s, an d p r ofession al lan gu age s in th e c on te m p or a ry world , as well as th e m ultip licity o f vo i c e s, th e
D i s e a s e I l l n e s s
S i c k n e s s H E A LT H
H E A LT H H E A LT H
DIS Comp lex ( D i s e a s e - I l l n e s s - S i c k n e s s )
F i g u re 3
Cad. Saúde Púb lica , Rio de Jane iro , 17(4):753-799, jul-ag o , 2001
in d ivid u ality of these vo i c e s, in short, an i n t e r -d ialo gu e a n -d an a l t e r-d ialo gue p resen t in t h e c o n s t ru c tion of d iscou rses on h e alth- d isease. Illn ess is n ot on ly con stitu ted by th e in divid ual p oin t o f view, b u t by m u ltip le a n d fre q u e n t l y con flictin g p ath ways; in th is sen se it is d ialog-i c. Even wh ialog-ile ialog-illn ess ialog-is syn th esialog-ized ialog-in fam ialog-ilialog-iar n a r ra t i ve s, lo ad ed wit h ge n d er an d kin sh ip p o l i c i e s, it is also (an d n ow as d isease) objecti-fied as a sp ecific form of p hysiological d isord e r in case p resen tations an d con versation s a m o n g p h y s i c i a n s, even if these objectification can b e s u bve r ted or resisted b y p at ien t s. Sic kn ess is im m er sed in a soc ial web in whic h eve r yo n e n egotiates th e con stitution of th e m ed ical ob -ject an d the gu idan ce of the m aterial b ody.
Th e secon d lim itation to th e an alysis of se-m an tic n etworks refers to the redu ced p ossib il-ity of re p resen tin g th e d iver sil-ity of for m s of au-t h o riau-ty an d resisau-tan ce associaau-ted wiau-th au-the m ed-ica l system ’s cen tra l ele m en t s. Se m an tic n et-w o rk s, albeit p rodu ced by p oet-wer an d au th ori t y s t ru c t u re s, can p rovide the n ecessary m ean s to u n d er sta n d h ow h e gem on ic fo rm s a re org a -n i zed a-n d re p rod uced, si-n ce they are cultura l l y r oo te d a n d su sta in d isco u rses an d p ra c t i c e s. Howe ve r, Go od (1994) ackn owled ge s t h at this relation sh ip b etween sem a n tic stru c t u res an d h egem on ic p ower relation s has n ot b een suffi-c ien tly d evelop ed by th e m ain au th ors in this t h e o retical field , as m ain tain ed by Yo u n g’s ra d-ical cri t i q u e.
The n otion of sem an tic n etwork should t h u s b e exp a n d ed to in d ic at e th a t t h e m e an in g o f sickn ess is n ot u n ivocal, b u t th e p rod uct of in -t e rc o n n e c -t i o n s. I-t is n o lon ger jus-t a syn dro m e o f m ea n in gs, b u t also a syn d r o m e of exp e ri-e n c ri-e s, word s, fri-eri-elin gs, a n d a c tion s in vo l v i n g d i f f e re n t m em b er s o f so ciety. Th is se t o f ele-m en ts is con den sed in the essen tial syele-m bols of the m edic al lexicon , im p lyin g th at such d ive r-sity can b e culturally syn th esized an d o bjecti-fied . Sem an tic n etworks con stitu te deep stru ct u res cth act lin k illn ess cto a cu lctu re’s fu n da m en -tal va l u e s, m ean wh ile rem ain in g outsid e of th e e xp licit c u lt u ra l kn owled ge an d awa ren ess o f th e society’s m em b ers, p resen tin g th em selve s a s n at u r al. Th is n ew an alytica l agen d a for se-m an t ic n e two rks (Go od , 1994) tre at s t h e DIS Com p lex as a n a rr a t i ve, b oth n a tur al an d cul-t u r al, resulcul-t in g fr om co n c re cul-t e, p a rcul-tially in d e-t e r m in ae-te sickn ess p ro c e s s e s, a ve rie-table scri p e-t m a rked by a p lot with differen t persp ective s.
Ad van cin g su ch critical p ersp ective, Gi l l e s Bib e au a n d Ellen Co r in sta te th at co n te m p o-ra r y c u ltu o-ra l a n t h ro p o l o g y, th ro u gh its in ter-p re t a t i ve an d ter-p hen o m en ological watershed s, h as p roven in cap ab le of dealin g with th e com
-p lexity of h ea lth an d sickn ess -p ro c e s s e s. T h i s n e c e s s a r ily re su lts fr om t h e e m p ha sis o n t he stud y of su bjective exp erien ces in fallin g ill an d th e reification of sickn ess n arra t i ve s, taken as au to n om ou s te xts, wit h o ut ever esta b lish in g rela tio n s with eith e r t h e ove r all soc io cu ltu r a l con text or th e d isease’s “o b j e c t i ve” d im en sion . Desp ite em p hasizin g th e im p ortan ce of cultu r-al vr-alu es an d the in fluen ce of th e sem an tic n et-w o rk con cep t in their et-work, Bib eau , Co rin , an d c o l l a b o rat ors (Alm eid a Filh o et a l., un p ub -lish ed m a n u scr ip t; Bib eau , 1988, 1994; Bi b e a u & Co r in , 1994, 1995; Co rin , 1995; Co r in e t al., 1993; Co rin & Lau zo n , 1992; INECOM, 1993) re a f f i r m th e n ee d for a m a cro-social a n d h is-t o rical ap p roach is-to u n d er sis-tan d local con is-texis-ts. This m ea n s esta b lish in g an e p ist em olo gica l, t h e o retica l, a n d m e th od o logic al con n e ct io n b e t ween d ifferen t d im en sion s of re a l i t y, art i c u -latin g a m et a-syn th etic th eor y or “glob a l p er-s p e c t i ve” (Bib eau , 1988) in ten d ed to in tegra t e essen tial sem eiologic, in terp re t a t i ve, an d p ra gm atic elegm en ts for a cu ltu ral gm odel of h ealth -d i s e a s e - c a re. In the p articular sp here of h ealth , the issu e is to exp lore the relation s b etween se-m e io logic systese-m s o f se-m ea n in gs a n d exte rn a l con d ition s fo r p r od u ction (th e econ om ic-p o-litical con text an d its h istor ical determ i n a t i o n ) an d th e exp erien ce of fallin g ill (Co r in , 1995).
Cad . Sa úd e Púb lic a, Rio d e Jane iro , 17(4):753-799, jul-ag o , 2001 From th is persp ective, Bibeau an d Co rin
ef-f e c t i vely p oin t to a n o u ve rt u reof m ea n in g in the health field , im plyin g a n ew view of th e DIS Com p le x. Th ey p rop ose u n d er sta n d in g th e fallin gill p rocess as based on th e ab ove m e n -tion ed “glo ba l p ersp ec tive”, lin kin g in d ivid u al t ra j e c t o ri e s, cu ltu ra l c od es, t he m a cro - s o c i a l con t ext, a n d histo rical d e term in a tio n . To t his en d , they ad van ce an an throp ological, sem eio-logic, an d p hen om en ological theoretical f ra m e-w o rk to stu dy local system s of sign ification an d action vis-à-vis health p ro b l e m s. Such system s a re roo ted in th e gro u p’s so cial d yn a m ics a n d c e n t ral cu ltu ra l values u n d er lyin g th e in d ivid -u al co n str -uc tion o f th e fallin g- ill e xp er i e n c e an d co llec tive c on str u c tion of t he soc ial p ro-d u ct io n o f sickn ess (Bib ea u, 1994; Bib ea u & Co rin , 1994, 1995; Co rin , 1995).
In t h e c om m u n ities’ sp h eres of sym b o lic p ro d u ction , c orp oral, lin gu ist ic , an d b e h av-i o ral sav-ign s are tra n s f o rm ed av-in to sym p tom s of a g i ven illn ess, a cq uir in g sp ecific c au sal m e an -in gs a n d ge n er at -in g given soc ia l re a c t i o n s, sh ap in g wh at Bib eau & Co r in (Bib eau & Co ri n , 1994) p rop ose t o ca ll th e “syst em of sign s, m e a n i n g s, an d p ractices of h ealth” (Sm p H). In g e n e r al, loca lly co n st r u cte d p o p u lar kn ow l-ed ge is p lural, fragm en tl-ed , an d even con tra d i c-t o r y. Po p ular sem eiolo gy a n d cu lc-tu ral m od els of in terp ret at io n d o n ot exist a s an exp licit b od y of kn ow l e d g e, bu t are for m ed by a va ri e d set of im agin ary an d sym bolic elem en ts, ri t u a l-i ze d a s rat l-io n al. Ac c o rd l-in g t o th ese au th or s, p op ular kn owledge ab out Health an d its coun -t e r p a r -ts (exp ressed in -th e DIS Co m p lex) ar e lin ked a n d exp re ssed in te r m s of socially an d h i s t o rically con structed Sm p H syste m s.
Sm p H system s t hu s sh ap e a p op u lar sem eiology of h ealth prob lesem s in con text. To ap -p ro ach th em system atically or “s c i e n t i f i c a l l y ”, th e au thors p rop ose to look beyon d th e p ro f e s-sion a l d ia gn o stic cr i t e ria o f t h e b iom ed ical m odel an d docum en t the p articu lar cases com -p risin g actu al cu ltu ral va riation s (Alm eid a Fi l-h o et al., u n p u b lisl-he d m a n u scr ip t; Bib eau & Co rin , 1994, 1995; Co rin , 1995). In t he d aily p rocess of defin in g categories an d re c o g n i z i n g c ases in th ese cat egori e s, “o rd i n a r y” p eo p le (the com m u n ity, accordin g to Bib eau & Co ri n ) d o n o t n e ce ssar ily fu n c tion by id e n tifyin g c l e a r-cu t categories of thou ght, bu t by p erc e i v-in g sim ilarities an d an alogies an d estab lish v-in g a co n tin u ity a m on g ca ses ac c ord in g to a ri c h an d flu ctuatin g ran ge of cri t e ria (Alm eid a Fi l h o et al., un p ublished m an u scrip t; Bib eau & Co ri n , 1994, 1995; Co rin , 1995). Com p on en t categ o ri e s of Sm p H system s are fragm en ted, con tra d i c t or y, p aor tially sh aored , lo ca lly con st oru cted , o org a
-n i zed i-n m u ltip le sem a-n tic a-n d p r a x e o l o g i c a l system s (i.e., stru c t u red in p ractices), in h istorical con text, an d ac cessib le on ly th ro u gh c on -c rete situation s – eve n t s, behaviors, an d n arrat i ve s. Th is m od e of caarrategorizaarration refers arrato ob jectm od e ls form ed by “Lakoff p ro t o t y p e s” in -stead of h iera rch ical classification s of d iscre t e, m u tu ally exc l u s i ve, an d stable categori e s, typ i-fied by for m ally co n sisten t logic. Th e con c ep t o f “p ro t o t y p e”, key to lin gu ist Ge o rge Lako ff’s t h e o ry (Lakoff, 1993), im p lies categories of flu -id, im p recise m ean in gs with re l a t i ve d egrees of s t a b i l i t y, d iscr im in ated by fuzzy lim its in d efin -itio n . Bec ause th ey d iffer from th e categori c a l logic p re vailin g in We s t e rn , Aristotelian th in k-in g, Lakoff p roto typ es ca n b e b e tte r u n d er-stood th rou gh alter n a t i ve system s like Za d e h’s fu zzy logic (as su ggested by Lakoff h im self ) or Newton d a Co s t a’s p ara-con sisten t logic (Co s-ta, 1989).
Cad. Saúd e Púb lica , Rio d e Jane iro , 17(4):753-799, jul- ag o , 2001
The epist emology of Health
Wh at h as b ee n d isc u sse d th u s far ap p ea rs t o sh ap e a cer ta in c h ron icle of a c on cep t’s re s i st a n c e. “He a l st h” is cerstain ly n ost a docile or sub -m i s s i ve ob ject of an alysis. It h as resisted -m ore o r less co m p et en t a ttem p t s at d om estica tion by th e scien ces of b oth stru c t u re an d in terp re-t are-tion . A cr ire-tica l in ve n re-t o ry of re-t h is effor re-t lead s on e to con clu de th at th e social an d an th ro p o-logical scien tific ap p r oac h t o th e Health issu e h as re ac h ed its lim it s, p r ovin g in c ap a b le o f d ealin g with the p ro p e rties of the ob ject-m od-el it in ten ds to con stru ct. Bu t is the q u est for a Ge n e ral T h e o ry of Health really feasib le, takin g th e h ealth con cep t as a given object-m od el? In s h o r t, can health b e treated as a scien tific con c ep t? Or, d o es th is u n d e r takin g en t ail a n u n d erlyin g p hilosop hical p roblem or som e essen -tial epistem ological obstacle? If it is p ossible to c o n c e i ve of Health as a con cep t, how can ep is-tem ology con trib ute to th e effort? Th is section is in ten ded to evalu ate th is set of qu estion s.
With ou t a dou b t, th e n atu re of Health con -stitu tes a secu lar p h ilosop h ic al q u estion , p er-h ap s of ter-h e m a gn itu d e of Ru s s e l l’s p a ra d ox or Hu m e’s p ro b l e m s. De s c a r te s id e n tified it an d Ka n t lat er syst em at ized it a s a b asic p r o b l e m fo r p h ilosop h y (Can gu ilh em , 1990). T h e re f o re let u s call it Ka n t’s Pro b l e m .
Am o n g th e c on te m p or a ry p hilosop h e r s who h ave focused on th e Health issue, Ge o rg e s Can guilh em d eserves sp ecial at ten tion . In h is i n a u g u ral work Le N orm al et le Pa t o l o g i q u e
(1978), Can gu ilh em in dicated th at the m ed ical d efin it ion o f n o rm a lity st em s largely fro m p h y s i o l o g y, fou n d in g a p ositivity th at im p ed es viewin g sickn ess as a n ew fo rm of life. T h e ref o re, d isease c ou ld n o t b e a d m itt ed a s a n ob -j e c t i ve d atu m , given th at p osit ivist sc ien tific m et h od s on ly h ave th e a b ility t o d efin e va r i-e tii-e s o r d iffi-eri-e n c i-e s, wit ho u t an y p o sitivi-e or n e g a t i ve vital va l u e.
From this p ersp ective, the n orm ality-p a t h o l-o gy a n d h ealt h -d isea se cl-o n cep tu al d yad s are n o t sym m et r ica l o r eq u ivalen t, to t h e ext en t that n orm al an d p athological do n ot con stitu te c o n t ra r y or con tra d i c t o ry con cep ts. Pa t h o l o g i-ca l d oe s n o t m ea n th e a b se n ce of n or m s, b u t t he p r ese n ce of o th e r vit ally in fer ior n o rm s, wh ich p re ven t th e in d ivid u al from exp eri e n cin g the sam e m ode of life allowed to h ealth y cin -d i v i -d u a l s. He n c e, for Can gu ilhem , p athological c o r resp on ds directly to th e con cep t of sick, im -p lyin g th e vita l o -p -p osite o f h ealth y. Po s s i b i l i-t ies in i-th e si-ta i-te of h eali-th a re su p er ior i-to n or-m al cap acities: h ealth con stitu tes a certain ca-p ac ity to ove rco m e t he cr ises d ete rm in ed by
th e forces of d isease to in stall a n ew p hysiolog-ical ord e r.
Re p resen tin g a h ist ori o g rap h ic wate rsh ed in th e Can gu ilh e m ian th eo ry o f th e n or m a l -p ath olo gica l te n sion , Mic he l Fou c au lt (1963, 1976) sought to in dicate h ow n ew stan d ard s of n o rm a lity em er ge d in t h e sp h ere of gen era l an d p syc h i a t ric m ed icin e. In t he c on te xt of 1 8 t h - c e n t u ry cu ltural re c o n s t ru ction , attem p ts we re m ad e to in terven e in h u m an in d ivid u als, th eir b o d ie s, t he ir m in d s, an d n o t on ly in t h e p h ysical en vir on m en t, to th ere by n or m a l i ze it for p rod u ction . To list th e n or m al p ossib ilities for h u m an yield s an d cap acities, as well as the p a ra m eters for n or m al social fu n ctio n in g, b e-ca m e t h e ta sk o f p syc h i a t r ic m ed icin e, p sy-c h o l o g y, an d ap plied sosy-cial ssy-cien sy-ces. From this p e r s p e c t i ve, th e im p licit con cepts in Fo u c a u l t’s w o rk r e vea l h is a d h ere n ce to a d efin ition of h ealth as an adap tive cap acity (or su b m ission ) to disciplin ary p owe r s.
Su b s e q u e n t l y, Can gu ilh em (1966) sta ted th at n o rm ality a s a life n or m co n st itu tes a b roa d er cate go ry, en c om p a ssin g he alt h y an d p ath ological as d istin c t sub -categori e s. In th is s e n s e, both h ealth an d sickn ess are n orm al, to the exten t th at b oth im p ly a c erta in life n or m , w h e re h e alth is a su p er ior life n o r m an d sickn ess is asickn isickn ferior osickn e. Health is sickn o losickn ger lim -ited to the persp ective of adap tation , n o lon ger u n re s t ricted obedien ce to the established m o d -el. It is m ore than th is, to th e exten t that it can con st it u te itself p rec isely by n on -ob e d ie n ce an d tra n s f o r m at io n . Ac c o rd in g to th e eld e r Can gu ilh em (1966, 1990), h ealth as th e p erf e c t ab se n ce of sic kn ess is situ a ted in th e field of d i s e a s e. The th resh o ld b etwe e n h ealth an d sickn ess is sin gu lar, a lth ou gh in flu en c ed b y f o rc es th a t tra n sce n d th e strict ly in d ivid ua l, like th e cu ltu ral, socioec on om ic, an d p olitica l g rou n d s (Cap o n i, 1997). In the fin al an alysis, th e in flu en ce of these con texts occurs at th e in -dividu al level. Ne ve rt h e l e s s, th is in flu en ce does n ot d irectly determ in e th e result (h ealth or s i c k-n ess) of this ik-n t erac tio k-n , to t he extek-n t th at its effects are su bord in ated to n orm a t i ve p ro c e s s-es of sym bolization .
Cad . Saúde Púb lica, Rio d e Jane iro , 17(4):753-799, jul-ag o , 2001 to p osit io n h ealt h as a n o b je ct ou tsid e of th e
field of kn ow l e d g e, where by it cou ld n ever be a scien tific con cep t, b ut rather a com m on p lace, p op u lar n otion , with in eve ryo n e’s reach.
Th e id ea th a t health is som eth in g in d ivid -ual, p ri va t e, un iqu e, an d sub jective has re c e n t-ly b een d efen d ed by th e em in en t p h ilosop h er Ha n s Ge o rg Ga d a m e r, o n e o f th e m ain exp o n en ts of c on t em p o ra r y h e r m en eu tic s (Ga d a -m e r, 1996). Ac c o rdin g to Ga d a -m e r, th e -m ystery of h ealth lies in its ellip tic, en igm atic ch ara c t e r. Health d oes n ot p resen t itself to in dividu als. It can n o t b e m easu red , b ec au se it en tails an in -t e rn al a greem en -t a n d can n o-t b e con -trolled by e x t e r n al fo rc e s. Gad a m e r go es so fa r as to say tha t th e m ystery of h ea lt h is equ iva len t to th e m y s t e ry of life. In h is op in ion , th e d istin ction b e t ween h ea lth an d illn ess ca n n ot b e c lear ly d efin e d. The d istin ction is p ragm atic, an d can on ly b e a cc esse d by t h e p erson wh o fee ls ill an d who, n o lon ger cap ab le of dealin g with th e d em an d s of life an d t he fear of d ea th , d ecid es to visit th e d octor. Ga d a m e r’s con clu sion (Ga-d a m e r, 1996) is sim p le: (Ga-d u e to its p ri va t e, p er-so n al, r ad ic a lly su b ject ive n at u re, h e alt h can n e ver be red u ced to an ob ject of scien ce.
Can guilhem (1990) would agree that h ealth is a p h ilosop h ic al issue to th e exten t that it es-cap es th e reach of in stru m e n t s, p ro t o c o l s, an d scien tific equ ip m en t, sin ce it is d efin ed as fre e an d u n con d ition al. This “p hilosoph ical health” would cove r, but n ot be con fu sed with, in divid -u al, p r i va t e, a n d s-u b jective h ealth . It is a p he-n om ehe-n o he-n with ou t a c ohe-n c ep t, em e rgihe-n g fr o m th e praxeological relation ship in th e p h ysician -p atien t en cou n ter, valid ated exc l u s i vely by th e sick su b je ct a n d his/ h er p h ysician . Clin ical k n owled ge is attribu ted to the m ission of ap p ly-in g a techn ology an d practice of p rotectly-in g th is s u b j e c t i ve, in d ividual health . Yet p h ilosop h ical h ea lth d oes n ot on ly in corp o ra te in d ivid ua l h ealth , b ut also its com p lem en t, re c o g n i z a b l e as a p u blic h ealth (i.e., a h ealth m ad e p u b lic).
Th e p h ilosop h er’s n ot ion o f p u b lic h ealth, re f e r r in g to ethical an d m etap hysical qu estion s (wh ich would resu lt for exam p le in the n otion s of u tility, qu ality of life, an d h ap p in ess), m ove s away fro m th e p u b lic h ealt h exp e r t’s con cep t of health, which u n derstan ds the state of h e a l t h of p op u la tion s an d it s d ete rm i n a n t s, b ot h in th e sen se of a com p lem en t to the ep idem iolog-ic a l c o n ce p t o f risk a n d as a re f e re n ce t o th e b roade r con cep t of th e radical n eed for h ealth . Th e co n c ep t of ra d ica l n ee d com es from th e p o s t - Ma rxist Hu n g a r ian p h ilosop he r Agn es Heller (1986), p rovid in g an esp ecially in tere s t -in g con ceptual op en -in g for a Ge n e ral T h e o r y of Hea lth en d eavo r, t o th e e xte n t th at it im p lies
health as som eth in g p ositive, albeit in th e p ar-tial sen se of fillin g an essen ar-tial lack or n eed in a su bject (like resistan ce or resilien ce) or society (as a p ositive h e alt h situ at ion ) (Pa im , 1996). Th is p roposal was ap p lied to the health field by R i c a rd o Bru n o Go n ç a l ve s, accord in g to wh om “h ealth n eed s cou ld be con cep tu alized as w h at m u st be ach ieved for a bein g to con tin u e to be a b e i n g” (Go n ç a l ve s, 1992:19) – I owe th is obser-vation to Ja i rn ilson Paim (p er son al com m u n i-c a t i o n ) .
Can guilhem (1990) is again st th e exc l u s i o n of h ealth as an object of th e scien tific field, an -ticip atin g a stan ce con tra ry to th at of Ga d a m e r. He con ten ds that h ealth is re a l i zed in the gen ot y p e, in oth e su b jecot’s life h isotor y, an d in oth e in -d i v i -d u a l’s rela tion sh ip to th e en viro n m e n t ; h e n c e, the id ea of a p h ilosop hical health wou ld n o t p reclu d e t akin g h ea lth a s a sc ien t ific o b ject. Wh ile p h ilosop h ical h ealth would en com -p ass in dividu al h ealth, scien tific h ealth wou ld b e p u blic h ealth , t h at is, a h ea lth in ess c on sti-t u sti-te d in o p p osisti-tio n sti-to sti-th e id e a o f m orb id isti-ty. Sin c e th e b o d y is t h e p r od u ct of c om p lex p ro cesse s of exch an ge with t h e en vir o n m e n t , t o t h e ext en t t ha t t h e se p ro cesses ca n con -t r ib u-te -to d e-t er m in e -t h e p h en o-typ e, h e al-t h would corresp on d to an im p lied ord er both in t h e b iolo gica l sp he re of life an d t h e m od e o f life (Can gu ilhem , 1990). As a p rodu ct/ effect of a given m ode of life, h ealth im p lies a feelin g of b ein g able to con fron t th e force of illn ess, th u s fu n ct ion in g a s a so r t of op en n ess tow a rd s so-cial ri s k s, as an alyzed by Cap on i (1997).
At th is sta ge o f h is a rgu m en t, Ca n g u i l h e m refers to Hy g i e n e, which b egin s as a tra d i t i o n a l m ed ic al d iscip lin e, m ad e of n or m s, n ot d is-gu isin g its p olitica l am b itio n of reis-gu latin g th e l i ves o f in d ivid u als. Begin n in g wit h Hy g i e n e, h ea lth b e co m es a n o b jec t of c alcu la tion a n d b egin s to lose its d im en sion as a p r i vate tru t h , receivin g an em p irical m ean in g as a set an d ef-fect of ob jective p ro c e s s e s. Can gu ilh em (1990) in sists th at h ealth is n ot on ly life in the silen ce of th e o rg a n s, as affir m ed by Ler i c h e, b u t also life in th e silen c e of social re l a t i o n s. It is fro m t his p ersp ective tha t we c a n in se r t th e d is-c ou rse o f is-colleis-ctive he alt h as we kn ow it. Ye t Can guilhem (1990) con ten d s after all th at sci-e n tific hsci-ea lth c o uld a lso a ssim ilat sci-e so m sci-e a s-p ec ts of in d ivid u al, su b je ct ive, s-p h ilosos-p h ical h ea lth , so th at n o t on ly sic kn ess an d h ealth i-n ess (or, u sii-n g a m ore u p -to-d ate term i i-n o l o g y, th e risks) sh ould be stu d ied by scien ce. Fi g u re 4 is an attem p t a t sch em atically d ep ic tin g the Cagu ilh em ian p osition on this issu e.
Cad. Saúde Púb lica , Rio de Jane iro , 17(4):753-799, jul-ag o , 2001
b e f o re. On t h e o n e ha n d , h e re c o g n i ze s th e h ealth co n c ep t’s p oten tially scien t ific q u a lity, sin ce e ven adm ittin g that th is does n ot refer to a n exist en c e, ra th er to a n or m with fu n c tion an d va l u e, “this does n ot m ean th at health is an em p ty con cep t” (Can guilh em , 1978:54). On the oth er han d, you n g Can guilh em fin d s n o ju stifi-cation for a sp ecific h ealth scien ce en d eavo r, at least at th e in d ivid u al level. In his own word s : “If health is life in th e silen ce of the organ s, t h e re is n o scien ce of h ealth p er se. Hea lth is organ ic i n n o c e n c e . An d it m u st b e lost, lik e all in n o-c e n o-c e , in ord er for k n ow led ge to beo-com e p ossi-b l e” (Can gu ilh em , 1978:76).
In th is sam e sen se, th e radically p h en om e-n o lo gica l Ga d a m e riae-n p e rsp ective ie-n d efe e-n se o f p ri va t e, sub jective, in h er en tly e n igm a tic h ealth wou ld ju stify ru lin g ou t the feasib ility of a scien tific ap p roa ch to h ealth . Howe ve r, I see a s a p a ra d ox t h e fact t ha t on e of Ga d a m e r ’s m ain p ro p o sa ls (Ga d a m e r, 1996) tu rn s o u t t o b e c ru cial fo r th e a d van ce m en t of a n a lter n a-t i ve fo rm u la a-tio n for a-t h e scien a-tific ob jec a-t of h ealth . Based on an etym ological argum en t, as is h is style, he d efen d s t he id e a t h a t he alth is inescap ably allen com p assin g, because its c o n -c ep t d ir e-c tly in d i-ca te s wh olen e ss o r t ota lity. From th is an gle, th e Ga d a m e rian n otion of th e “health en igm a” en d s u p open in g th e way for a
syn th etic (or m eta-syn th etic, as we shall see l a t-er) ap p roach to th e scien tific con cep t of health . Th e Argen tin e ep istem ologist Juan Sa m a j a , au th or o f the classic Ep istem ología y M e t o d o-logía (Sam aja, 1994), a rare case of a p hilosop her with train in g an d in terest in Public Health, takes Can guilhem as his p oin t of d epart u re to in ve s t i-gate the con dition s allowin g for a scien tific the-o ry the-of health . Sam aja (1997) cri t i c i zes b the-oth th e Canguilhem ian p rem ise that the health concept is con cern ed fun dam en tally with the biological world a n d th e im p lic it Fou ca u lt ia n p re m i s e th at p roposes a p u rely social or m erely d iscu r-s i ve (ideological-p olitical) con cept of h ealth .
Ac c o rd in g to Sam aja (1997), th e p ara d i g m of Com p le x Ad a p t i ve Syst em s c ou ld ser ve a s th e ep istem ologic al b asis for ove rc om in g t he b io logical- soc ial an t in om y, given con ce p t u a l d em an d s alrea d y esta b lish ed b y th e d eve l o p -m en t a n d p ra ct ic al u se of th e “ h e a l t h” n o tion in m od ern lay a n d tech n ical discou rses. In h is op in ion , on e m u st con c eive of th e h ealth con -ce p t a s an ob ject with d istin c t h iera rc h i c a l f a c e t s, wh ic h “a l l ow s on e to d ialectically a p -p roa ch th e h ea lth -d isease d ya d an d th e -p ra c-tices com p risin g it, leavin g room for th e re c o gn itiogn of variou s p lagn es of em ergegn ce, ign a com -p l ex system of a da-p t ive -pro c e s s e s” (Sa m a j a , 1 9 9 7 : 2 7 2 ) .
In c o r p o ratin g elem en ts from con tem p ora ry c r itical h erm e n e u t i c s, Sam aja p ro p oses th at th e ob jec tm od el “ h e a l t h” sh ou ld op erate u n -der four essen tial on tological determ i n a t i o n s :
N o r m a t i ve n e s s. Th e h ealth ob ject is n orm a-t i ve b ecause ia-t exisa-ts in an d con sisa-ts of a-th e he ra rch ical in therfaches in d yn am ic social an d b i-ological system s, b o th rea l a n d id ea l, wh ich sh ap e the hu m an world by m ean s of p ro c e s s e s i n volvin g th e establish m en t an d evaluation of n o rm s for existen ce.
D ra m a t i c i s m. The h ealth object is d ra m a t i c in two sen ses: first , in t h e re c u r s i ve sen se, to the exten t th at it exists in an d con sists of itera-t i ve, re p ro d u c itera-t i ve, an d itera-tra n s f o rm a itera-t i ve p ro c e s ses of the h iera rch ical in t er face s; sec on d , d ra -m atic in a con flictive sen se, given th at each h ie ra rc h ic al o rd ier m ain ta in s a high lieviel of au -ton om y an d there f o re of vuln erab ility vis-à-vis the in terf a c e s.
Re f l ex i v i t y. Th e h ealth object is re f l e x i ve be-cau se it exists in an d con sists of the field of the p rofesse d se n se s a n d p ra c tices exp er i e n c e d t h rou gh “p ro d u c t i ve - a p p ro p ri a t i ve (sp ecifical-ly h um an ) con du ct”.
Hi s t o r i c i t y. Th e h ea lth o b ject h as a n on to -socio-gen etic n atu re: it exists in an d con sists of th e d ialectic of str u c t u ra l p r ocesses th a t re c a -p itulate -p ast gen eses.
S I
D
N o rmal he alth (sig ns & sym pto ns)
So cial he alth (Sm pH) Private he alth (fe e ling )
Scie ntific he alth (co nce p t)
H e a l t h i n e s s Ind ivid ual he alth
Philo so phic al he alth (value )
DIS Complex and M odes of Healt h
F i g u re 4
Cad . Saúde Púb lic a, Rio d e Jane iro , 17(4):753-799, jul-ag o , 2001 In this p athway of con stru ction , which p u
r-p o sely takes h ealth a s a soc ial va lu e (an d a l-m o st as a n id ea l typ e), Sa l-m aja h igh ligh ts its co m p lex, p lu ra l n atu re, fu n d am en tally o n e of lin kin g m ultip le determ i n a t i o n s :
The object of Health Scien ces, as a com p lex object th at con tain s sub -objects with d iffere n t l e vels of in tegration (cells, tissu es, org a n i s m s ; p e r so n s; fa m ilies; n eigh b or h ood s; o rg a n i z a-tion s; cities; n aa-tion s...), en tails a large n u m ber of hier a rc h ical in ter faces an d a n en or m o u s am o u n t o f in form a tion , in wh ich its exp er i-en ces an d p ostulation s (both true an d false) on n o r m a l/ p at h o logica l, h e alt hy/ ill, an d c u ra -t i ve / p re ve n -t i ve acq uire m ean in gs an d dra m a - t-ic d im en sion (Sam aja, 1997).
Th e au th or d eri ves from these reflection s a s e ries of ep istem ological con clusion s, am on gst wh ich h e h igh ligh ts that th e th eoretical h ealth field em erges from the p r od u ction an d form u -latio n o f wh a t h e ca lls a “p o l i t o m o r p h o u s” k n owledge on the n orm al-p ath ological d ialec-t i c. To ialec-this en d , ialec-the in ialec-terd i s c i p l i n a ry field of ialec-th e hea lth scie n ces is stru c t u red on th e co gn it ive p rodu ction of th e va riou s sub ord in ate objects, re vealin g differen t p lan es of em ergen ce an d hi-e ra rch ic al in t hi-er f a c hi-e s. Th hi-e fu n d am hi-en ta l q uhi-es- uestion in th is ep istem ological in vestigauestion con -sists p recisely of the iden tification of th e stru c-t u rin g in c-terfaces in c-th e m ulc-tifacec-ted c-toc-talic-ty of the object-m od el “ h e a l t h”. Ac c o rdin g to Sa m a-ja (1997), t h e m a in in t erfac es o f He alt h a re :
“m olecu le//cell (sp ecific category :a u t o p o i e s i s ) ; cell//organ ism (category : o n t o g e n e s i s ) ; o r g a n -ism //society (ca tegory : s t r u c t u ra l cou p lin g)”. ( Sam a ja d oe s n ot re fer to an im p ort an t in t er -m e d iate in t erf a c e, a lb e it on e th at occ u rs a t a su b in d ivid u al level, in volvin g orga n s a n d sys-tem s in the organ ism , an d whose sp ecific cate-g o ry m icate-ght b e differen tiation . I owe th is observation to Lígia Vi e i ra da Si l va, by way of person -al com m u n ication .) In add ition , he p rop oses to co n sid er th e in ter faces in th e societal sp h ere, p layin g out as follows: b iosociety/ / gen tilic so-c i e t y; gen tiliso-c soso-ciety/ / p olitiso-ca l soso-ciety. In s h o rt, Sa m a j a’s con tribu tion is a critical p ro p o-sition vis-à-vis Ca n g u i l h e m’s th in kin g, yet on e th at in t erm ed iat es it , allowin g for its in stru -m e n ta liza tion a s a fra-m e of re f e ren c e for a Ge n e ral T h e o ry of He a l t h .
Tu rn in g to b o th th e sc ie n ces o f sym b o lic system s an d th ose of org a n i zed b iological sys-t e m s, Sa m aja p rop o se s a p e rsp ec sys-tive wh ich d ou b tle ss ove rcom e s Ka n t’s Prob lem an d u p -dates Ca n g u i l h e m’s th eory con cer n in g th e n ew p a rad igm a tic d evelop m en t s in con tem p ora r y s c i e n c e. Aft er all, in Ka n t’s tim e on ly p h ysic s, a s t ro n o m y, an d n atu ral histo ry we re c on sid
-e r-ed sci-e n c-e. It is n o t su r p r isin g th at fo r th -e fo un d in g p hilosop her of m od er n ep ist em olo-g y, it ap p eared in ad m issib le to con sider a ra d i-c ally su b je i-ctive q ue stio n (like He alth , at least a t th e in d ivid u al level) as a p oten tial p r o b l e m for scien ce. We shou ld n ot forget that scien tific p s yc ho logy an d an th rop olo gy h ad still n ot b e en created , that social re l a t i o n s, th e u n c on -s c i o u -s, an d t he -sym b olic c on t en t-s of cu ltu re an d history we re still n ot scien tific objects, an d t h a t th e eth n ogra p h ic m e th od h ad n ot b een d e velop ed. In ad dition , clin ical p ractice tod ay is n ot wh a t it used to b e (a s fo r exa m p le in you n g Ca n g u i l h e m’s tim e). Biotechn ology ha s i n va d e d / t resp assed m olecu les, tissu es, org a n s, the hu m an body. Diagn ostic classification s, th e gen etic code, an d th e im m u n e system h ave in c rea sin gly b ec om e th e ob je ct of so ca lled in -f o r m at io n scien c es. A wo rd o-f c au tion is t h u s in ord er vis-à-vis t h e ra d ical co n stru c t i o n i s m p e rm ea tin g an y Ca n gu ilh em - like a n alysis, wh ic h by ap p ear in g t o ign ore th e n a tu ra l n e s s of d isease, becom es a source of ab stract re f l e c-tion wh ich fails to in stru m e n t a l i ze a con sisten t c ritiqu e of th e h egem on ic m ed ical m odel.
M odeling health
As d iscu ssed a b ove, t he b io m e d ica l co n ce p -t ion s of h eal-t h a n d -t h e socio cu l-tu ra l -t h eo ri e s o f h ealth -d isea se p resen t m ajor lim itat io n s t h at red u ce th eir va lu e as a c on c ep tu al re f e r-e n cr-e to d r-ea l wit h t h r-e m u ltid im r-en sio n ality o f t h e DIS Com p lex (d isease-illn ess-sic kn ess). Fu n c tio n a list m ed ical so ciology d eve l o p e d p rocessual m odels for th e social determ i n a t i o n of illn ess th at on ly tan gen tially allow on e to in fer health as th e resu lt of a daily p rocess of con -s t r uctin g -social re -s p o n -s e -s. Neither h a-s m edical a n t h ro p ology ever p rop ose d to d efin e a t h eo-retical category called “ h e a l t h”, focusin g on th e e t h n o g rap hic specificities of th e n otion of sick-n ess asick-n d its c orre l a t e s. Desp ite th eir th eore t i-c a l an d m e th o d o logii-c al ad va n i-c e s, b ot h p er-s p e c t i veer-s focuer-s on cu ra t i ve p ra c t i c e er-s, an d in er- so-far as n ecessary defin e health as the ab sen ce of illn ess or sickn ess.
