Abstract

The purpose of this article is to revisit two authors with the intent to analyze the narratives constructed in two texts. In the first one, the narrative analyzed was the one pertaining to the elaboration of sociological theories in social medicine, and in the second, it was the one related to qualitative research in Health. The macro dimension of narratives, in the sense given by Maines of the possibilities of building a sociology of narratives and a narrative of sociology, will be the object of this study. The texts analyzed were written in the 1980s by JCM Pereira and MCS Minayo.

Key words
Narratives; Sociology; Pereira; Minayo; Social medicine; Qualitative research

Introduction

According to Hydén¹1 Hydén L-C. Illness and narrative. Sociol Health Ill 1997; 19:48-69., the concept of narrative starts its trajectory in studies on medicine and illness in the early 1980s, but ten years later, “the place of illness narratives in the work of medical sociologists and anthropologists is undisputed”²2 Raine S. The narrative turn: interdisciplinary methods and perspectives. Student Anthro 2013; 3:64-80.. In the ‘90s, the researchers were “beginning to focus more on analyzing narratives and the function of narratives in social contexts”²2 Raine S. The narrative turn: interdisciplinary methods and perspectives. Student Anthro 2013; 3:64-80., referred to by Maines³3 Maines DR. Narrative’s moment and sociology’s phenomena: toward a narrative sociology. Sociol Q 1993; 34(3):17-38. as “the narrative’s moment”. For him, “the genuine narrative sociology” can have two sides: it can be“sociology of narratives” and “more inclusively and reflexively include sociology’s narratives”.

This article aims to revisit in two texts of the 1980s how the narratives are constructed. In the first one, the narrative analyzed was the one pertaining to the elaboration of sociological theories in social medicine, and in the second, it was the one related to qualitative research in health.

Pereira - the classics in the construction of the narratives of health practices

Sociologist José Carlos Medeiros Pereira (1935-2009), whose option for healthcare comes from his joining the Department of Preventive and Social Medicine of the School of Medicine of USP/Ribeirão Preto in August 1976, and he is the author of a study on the relationships between the classics of sociology and health. His refined theoretical training will be reflected on his associate professorship thesis Explicação sociológica na medicina social, submitted in November 1983 (published in 2005)⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006., which extensively used the theoretical formulations of Fernandes (1920-1995)⁵5 Fernandes F. Fundamentos empíricos da explicação sociológica. São Paulo: Cia. Editora Nacional; 1967., who “Dialogued with the main currents of thought of the past and present, from Spencer, Comte, Marx, Durkheim and Weber, to Mannheim, Parsons, Merton and Marcuse, among others”⁶6 Ianni O. A sociologia de Florestan Fernandes. Est av 1996; 10:25-33..

This theoretical impregnation is displayed in the work of Pereira, who analyzed functionalism, comprehensive sociology and dialectical materialism in the 70’s. According to Pereira⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006., “When we talk about sociological explanation of sociomedical phenomena, we refer primarily to the social processes linked to the social practice of medicine”.

He begins this depiction by developing two long chapters on scientific activity and on the scientific approach to reality, noting that Sociology “is the social science that best allows the turn of perspectives that we advocate in order to broaden and deepen the study of sociomedical phenomena”⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006..

Then, he re-examines the functionalist paradigm, exemplifying it with the study about Enfermagem como profissão by Ferreira-Santos, which highlights

the social standing of nurses (...), a profession structurally linked to the female sex, socially subordinate to the male sex in the current asymmetric division of labour in our society, the pattern of submission is reinforced by their relationship with doctors, mostly men⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006..

He emphasizes functional connections between the social system and the role of nurses in his research.

Another work not considered to be “properly functionalist” is the one by Freire Costa (Ordem médica e norma familiar) on the “roles that hygiene undertook in the city of Rio de Janeiro in the middle of the last century [19^(th) century] in order to adjust the social behavior of free white families, who were also property owners, to the new objective conditions of existence”. He notes that “sometimes, analysis slips into the dangerous grounds of considering hygiene as the cause of the transformations to which one references”, but “it generally remains true to the consideration that sanitizing measures constituted an effect of the relatively profound transformations (...) which occurred in Brazil (...)”⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006..

In the field of mental illness and psychiatry, Pereira⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006. “tries to extract elements of a functionalist analysis” from Birman’s study entitled Psiquiatria como discurso da moralidade, in the France of 1793-1850.

Not having found examples of application of the comprehensive Weberian method in Brazilian social medicine, he examines medical assistance within this perspective. He highlights the tension between the medical sphere and other social spheres in the behavior of the social actors (doctors): acquisition of profits, salaries, maintenance of power relations, etc., and the emphasis on professional ideals and social practices of promotion and prevention of health, difficult to be programmed, including on the part of the beneficiary population, who is more interested in short-term measures by characterizing prevention as “something very distant and hazy”⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006..

Regarding the dialectical method, the analysis focuses in the master theses by Mendes-Gonçalves - Medicina e história: raízes sociais do trabalho médico, Nogueira’s Medicina interna e cirurgia: a formação social da prática médica and Donnangelo’s Saúde e sociedade. In them, he stresses the importance of the use of the dialectical method, especially in its application to history in order to explain social phenomena - relationships, processes, and institutions - linked to the social practice of medicine. The three studies deal with “problems of change, whether of medical work, the design of the object and purpose of medicine, social medicine practices, the social situation of the doctor, etc.”⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006. that lend themselves to a dialectical approach. They try to “capture reality in its complex and contradictory aspects (...), from the analytical to the synthetic plane, so that the total examined ends up displaying itself pregnant with significant determinations”⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006..

According to Pereira, these studies which address the social practices of medicine “are both object of sociology and of social medicine. The latter, being a medicine of borders, is, in large part, sociology in and of medicine”⁴4 Pereira JCM. A explicação sociológica na medicina social. São Paulo: Editora Unesp; 2006..

At this point it is worth returning to the analysis by Ianni⁷7 Ianni AMZ. O campo temático das ciências sociais em saúde no Brasil. Tempo soc 2015; 27(1):13-32., to compare the two versions (1986 and 2003) of Pereira’s article Medicina, saúde, sociedade, especially with regard to medical assistance, present in the 1983 thesis. Ianni⁷7 Ianni AMZ. O campo temático das ciências sociais em saúde no Brasil. Tempo soc 2015; 27(1):13-32. mentions that, for Pereira⁸8 Pereira JCM. Medicina, saúde e sociedade. Estudos de Saúde Coletiva 1986; 4:29-37., health and disease are both biological and social objects, and that he recognizes medical-clinical assistance as a social institution creating interactions in the medical field. The health object would then have the preeminence of the medical clinic. In the 2003 edition, Pereira (apud Ianni⁷7 Ianni AMZ. O campo temático das ciências sociais em saúde no Brasil. Tempo soc 2015; 27(1):13-32.)

develops his criticism of that clinical, individual, biomedical object (...) that carries an excess of biological components and the absence of a social component. (...) the clinic sees the individual only through his biological character, and thus manipulates him - specific, individualized, relative to the etiological agents and/or causal factors of diseases - as opposed to more general, collective and social contexts, determinants of the health-disease process.

According to Ianni⁷7 Ianni AMZ. O campo temático das ciências sociais em saúde no Brasil. Tempo soc 2015; 27(1):13-32., this proposal is paradoxical for, “on the one hand, he recognized the nature of the individual as social being (...)” and that “the disease would manifest in what this individual represented or expressed as social. On the other hand, he did not develop a theoretical and epistemological critique about the biological design itself, which is, also, and above all, a social and cultural product”.

From the Levine’s perspective⁹9 Levine DN. Visions of the sociological tradition. Chicago: The University Chicago Press; 1995., Pereira’s narrative classifies as a pluralistic - theoretical and humanistic diversity - use of classics.

Due to the methodological possibilities of functionalism, of dialectics and comprehensive sociology, the author highlights the possibility of complementarity, in a reference to Fernandes⁵5 Fernandes F. Fundamentos empíricos da explicação sociológica. São Paulo: Cia. Editora Nacional; 1967..

Minayo - the narrative of and in qualitative research

A privileged field for the narrative approach, qualitative research has in Maria Cecília de Souza Minayo an original and creative author, promoting not only methodological developments, but creating conditions, including institutional ones (CLAVES - Latin American Centre for the Study of Violence and Health, nowadays the Department for the Study of Violence and Health Jorge Carelli/Ensp/Fiocruz), for the advancement and support of a diverse field of research. Sociologist and anthropologist, with a Master’s degree in Social Anthropology and a doctoral degree in Public Health (DrPH), her area of expertise is Collective Health and its developments in the methodology of qualitative research in health, social sciences in health, violence and health, health policies and evaluation of social and health programs.

Right now, the goal is to point out her absolute contribution to the field of qualitative research. In 1989, she submitted her doctoral dissertation -O desafio do conhecimento. Metodologia da pesquisa qualitative em saúde¹⁰10 Minayo MCS. O desafio do conhecimento. Pesquisa qualitativa em saúde. 9ª ed. São Paulo: Hucitec; 2006., edited this year, now in its 14th edition.

It is “a [didactically written] text which focuses on the inside of the field left behind by the classics, without losing the perspective of the scientific dynamics that only empirical research can provide”¹¹11 Nunes ED. Resenha O desafio do conhecimento. Cien Saude Colet 2007; 12(4):1087-1088..

At this point it is pertinent to situate how Cecilia narrates the paths taken during this task of researching.

(...) I want to clarify that I am a part of the ideas of comprehensive social science and of the dialectic-hermeneutic that tend to continuously recover the role of individuals in processes, showing that their protagonism has been critical to the execution of social changes. Obviously this line of thought does not equal nor strengthens the thought of the traditional and conservative history that grants to Kings, powerful people and rulers the merit as holders of key changes. Nor is it situated within the positivist sociology or mechanistic Marxism for which individuals either are reflections of the collectivity or carry out interchangeable functions in processes of change. On the contrary, when putting emphasis on the actions of a few individuals, the chains that assign privilege to subjects (individual, group and collective) show that there is a dialectic between the wishes and the wills turned to a specific social action that underlies every social construct; the mediations of institutions that are constructed or forwarded so that these desires and wishes may be achieved; and certain individual and collective actors who engage in the concrete realization of the projects’ institutionalization. Certainly, without the commitment of one part in this virtuous triangle, history would not be the same¹²12 Novaes MR. Contribuições ao pensamento social em saúde no Brasil [tese] Campinas: Universidade Estadual de Campinas; 2004..

The book analyzed reaffirms itself as a tractatu of qualitative methodology that carries in its pragmatic formulations the theoretical density that supports them. In Cecilia’s words:

I always try to relate theory and method, showing that there is no method without theory and vice versa. Every time you work on a theory, at the same time you have to work with its application; it is executed in its own application, which is the methodology¹²12 Novaes MR. Contribuições ao pensamento social em saúde no Brasil [tese] Campinas: Universidade Estadual de Campinas; 2004..

It is a methodology that is handcraftedly constructed and narrated. Here, the reference to Benjamin¹³13 Benjamin W. O narrador: considerações sobre a obra de Nikolai Leskov. In: Benjamin W. Magia e técnica, arte e política: ensaios sobre literatura e história da cultura. São Paulo: Brasiliense; 1994. p. 197-221. is immediate, the narrative as

a handcrafted form of communication. It is not interested in conveying the ‘purity’ of the thing narrated in itself, as an information or a report. It dips the thing in the life of the narrator to then remove it from him. In this way, the narrator’s mark is imprinted in the narrative, like the potter’s hand is imprinted in the clay pot.

For Cecilia, the sociological practice is experienced as a craft, and social research is experienced as a tool of an intellectual itinerary associated to a pedagogical practice, which Bourdieu et al.¹⁴14 Bourdieu P, Chamboredon J-C, Passeron J-C. Ofício de sociólogo: metodologia da pesquisa na sociologia. 7ª ed. Petrópolis: Vozes; 2010. call Pedagogy of research. According to these sociologists,

Research education that has as project exposing the principles of a professional practice and, simultaneously, inculcating a certain attitude towards this practice, that is, providing the essential tools for the sociological treatment of the object and, at the same time, providing an active disposition in using them appropriately; one must sever their ties with pedagogical discourse routines to restore the heuristic force of the concepts and operations that have been more thoroughly “neutralized” by the ritual of canonical presentation.

In theory, qualitative methodologies are

understood as those able to incorporate the matter of meaning and intentionality as inherent to actions, to relations and to social structures, these last ones being taken both in their advent as well as in their transformation, as significative human constructions¹⁰10 Minayo MCS. O desafio do conhecimento. Pesquisa qualitativa em saúde. 9ª ed. São Paulo: Hucitec; 2006..

Cecilia develops the narrative by covering: the basic concepts about methodology and qualitative approaches, formalized within theory, epistemology and methods; the construction of the research project and its exploratory stage; the role of theory, strategies and techniques in fieldwork and the stage of analysis of the qualitative material. Throughout the narrative, the author imprints analytical developments referenced in the classics of sociology and anthropology, and philosophical basis that support arguments in the construction of the field of qualitative research in health itself. Cecília bases her theoretical choice on a construction of research that crosses subject matters and boundaries at the interface of the social sciences.

This discourse is dialogical in the sense given by Levine⁹9 Levine DN. Visions of the sociological tradition. Chicago: The University Chicago Press; 1995. [who admits systematization, theoretical plurality and use of the classics], but expanded to refer to research focused on the understanding of the subjects analyzed - “from the perspective of the actors in subjectivity”¹⁰10 Minayo MCS. O desafio do conhecimento. Pesquisa qualitativa em saúde. 9ª ed. São Paulo: Hucitec; 2006.. In her 2012 essay, there are some “keys” to understand the methodology she uses when self-evaluating her work. She creates a decalogue, identifying nouns and verbs that are structural in regards to qualitative research: experience, living, common sense and action; to understand, to interpret, to approach dialectically. She retakes the steps of research highlighting that the researcher, when working on their empirical material, ordering and organizing it, must:

engage on information and field observations, build a typification of the material collected in the field and make the transition between empiricism and theoretical elaboration and put second-order interpretation into practice. The understanding provided by attentive, deepened and engaged reading that gave rise to the empirical categories or units of meaning, at that time, should deserve a new theorization process¹⁵15 Minayo MCS. Análise qualitativa: teoria, passos, fidedignidade. Cien Saude Colet 2012; 17(3):621-626..

Final considerations

I believe that, within the proposal, this article has reached its objectives. The choice for sociology’s narrative - “viewing sociologists as narrators and thereby inquiring into what they do to and with their’s and other people’s narratives”³3 Maines DR. Narrative’s moment and sociology’s phenomena: toward a narrative sociology. Sociol Q 1993; 34(3):17-38., which does not minimize the importance of the sociology of narratives, is made clear. The 1980s are mentioned as the time of emergence of the narrative about illness, but studies on chronic illness “in terms that are social - not just medical” are prior to this date¹⁶16 Strauss A. Chronic illness. In: Conrad P, Kern R, editors. The sociology fo health and illness: critical perspectives. New York: St. Martin’s Press; 1981. p. 138-149. [emphasis added]. Pioneers in this subject, two names are canon: Kleinman¹⁷17 Kleiman A. The Illness Narratives: Suffering, Healing and the Human condition. New York: Basic Books; 1988. and Good¹⁸18 Good B. Medicine, rationality and experience: an anthropological perspective. Cambridge: Cambridge University Press; 1994.. Contemporary, Kleinman is a doctor, psychiatrist and social anthropologist, whereas Good is a social anthropologist, and they worked together on many projects and compilations. It is interesting to note that both of them dedicated themselves to studying the experience of becoming sick in different cultures: American, Chinese, Iranian and Indonesian.

In his book, Kleinman¹⁷17 Kleiman A. The Illness Narratives: Suffering, Healing and the Human condition. New York: Basic Books; 1988. describes his clinical experience since the first observations in the medicine course in the 1960s. From the concepts of illness and illness narrative, his report on clinical cases are about pain, neurasthenia, the care for the patient coping with a chronic disease, the relationship with death, the stigma and shame of becoming sick, the social context of chronicity, the creation of an imaginary disease, hypochondria, and how to care for the chronically sick. For him,

The illness narrative is a story the patients tells, and significant others retell, to give coherence to distinctive events and long-term course suffering. The plot lines, core metaphors, and rethorical devices that structure the illness narrative are drawn from cultural and personal models for arranging experiences in meaningful ways and for effectively communicating those meanings … The personal narrative does not merely reflect illness experience, but rather contributes to the experience of symptoms and suffering¹⁷17 Kleiman A. The Illness Narratives: Suffering, Healing and the Human condition. New York: Basic Books; 1988..

For Atkinson¹⁹19 Atkinson P. Illness Narratives Revisited: The Failure of Narrative Reductionism. SRO 2009; 14(5):16 [acessado 2017 Dez 20]. Disponível em http://www.socresonline.org.uk/14/5/16.html
http://www.socresonline.org.uk/14/5/16.h... ,

Kleinman advocates close attention on the part of physicians to their patients narratives, suggesting that such a perspective would encourage the equivalent of an ethnographic understanding of the patient and her or his lifeworld of illness experience.

He warns that,

In recent years, we have witnessed an extension of the narrative turn that advocates not merely analytic attention to illness narratives, but a form of narrative medicine that places narrative work at the heart of medical professional practice and competence¹⁹19 Atkinson P. Illness Narratives Revisited: The Failure of Narrative Reductionism. SRO 2009; 14(5):16 [acessado 2017 Dez 20]. Disponível em http://www.socresonline.org.uk/14/5/16.html
http://www.socresonline.org.uk/14/5/16.h... [emphasis added].

Good¹⁸18 Good B. Medicine, rationality and experience: an anthropological perspective. Cambridge: Cambridge University Press; 1994., unlike Kleinman, deals with epistemological issues and what he calls syndrome of experience, defined as “a set of words, experiences, and feelings which typically ‘run together’ for members of society”. The author himself illustrates this point with his experience while researching the categories of people’s illness in Iran and in American health clinics - “our work has explored the diverse interpretive practices through which illness realities are constructed, authorized, and contested in personal lives and social institutions”. It should be noted that Good always sought to establish a relationship between the individual and cultural context and the notion of subjectivity. In a compilation alongside Kleinman and Biehl²⁰20 Biehl J, Good B, Kleinman A. Subjectivity: ethnographic investigations. Berkeley, Los Angeles: University of California Press; 2007., this last subject is broadly debated upon, both as empirical reality and as analytic category. In the field of Medicine, Good continues investigating the relations between culture and psychiatric disorders.

Through these final considerations, quoting Kleinman and Good helps to redetermine what Maines³3 Maines DR. Narrative’s moment and sociology’s phenomena: toward a narrative sociology. Sociol Q 1993; 34(3):17-38. calls the creation of a narrative sociology. Moreover, to demonstrate that both in the texts analyzed in the article as well as in the references to Kleinman and Good, which are closer to social anthropology, there is what Maines had already warned, that “a sociology would encompass the sociology of narratives, or the study of narratives from the standpoint of sociology’s domain interests, and it would more inclusively and reflexively include sociology’s narratives, viewing sociologists as narrators (...)”, but he adds that “this duality of focus is at best sensitizing, with very fussy edges and a center yet to be created”.

Acknowledgments

To CNPq Bolsa Produtividade IA.

The author thanks Espaço da Escrita - Coordenadoria Geral da Universidade - Unicamp - for the language services provided.

References

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