DEBATE DEBATE

To be necessarily precise... or precisely necessary?

"We end up shaping the world as if it allowed itself to be reduced, here and there, to intelligible elements. Sometimes our senses are sufficient for this purpose, and other times more ingenious methods are employed, but empty spaces are left. The attempts remain full of gaps (...)" (Paul Valéry, 1998).

Once again, Naomar de Almeida Filho has produced an essay in which his undeniable talent as scholarly bricoleur emerges clearly, with his skillfully fertile innovation in the field of philosophical reflection on health. For those who are unaccustomed to treading on such arid ground, it is a landscape which can give one the impression of dangerously approaching innocuousness and/or irrelevance in the face of the instrumental pressures increasingly characterizing the health domain. Yet in this case the author has constructed a vigorous and stimulating conceptual and epistemological framework, under the preliminary format of what he refers to as a "General Theory of Health", wisely explaining beforehand the caution required for such a daunting task.

The synthesis is extremely helpful in the presentation to the socio-anthropological (functionalist, phenomenological, semeiologic) and epistemological approaches as a prior review to the proposed systematization of 'modes of health' that concludes the essay.

My modest attempt to contribute to the debate is based on two points which tend to juxtapose: (a) the question as to whether "health [can] be treated as a scientific concept" and (b) the "hint of doubt" mentioned by the Bahian epidemiologist as to the possibility of Gadamer being right. In other words, it becomes compelling that health is something individual, private, unique, and subjective [indeed, in my view, not a very simple conclusion, contrary to what Almeida Filho contends, since if the conclusion were simple it would not entail the serious implication of making the 'scientificization' of the object health problematic].

On this point, I believe that it is appropriate to consider the uncomfortable possibility of a fleeting and simultaneous "coexistence" of aspects that are defined/undefined, precise/imprecise, accessible/inaccessible, unknown - potentially cognoscible/unknowable - incognoscible, in the demarcation of what health finally is. As Moles (1995:45) puts it, "the human spirit is fluid in its functioning, ambiguous in its concepts, and vague in its definitions". According to the latter author, one of the categories of the imprecise relates to "phenomena that are vague in essence (author's emphasis), or in which the concepts used to enunciate them are themselves vague, perhaps inadequate, but which are the only ones we have available" (Moles, 1995:19). In short, the words of Moles (or Valéry's epigraph) appropriately represent my impressions while reading Almeida Filho's propositions.

More specifically, I wish to highlight several issues for discussion on this stimulating article:

The preliminary establishment of a "semantic demarcation", or correspondence between the terms used in English and Portuguese (disease = patologia, disorder = transtorno, etc.) is not without side effects. We know that words have the stubborn "property" of unmasking themselves in the face of our attempts to circumscribe them in stabilized meanings. Visibly, as in Figure 1, to use patologia to mean both "pathology" and "disease" may lead to misunderstandings. I do not believe that to refer respectively to the "Canguilhemian (i.e., sub-individual) sense" or to the "structural (individual) register" satisfactorily resolves this focus of potential equivocation.

I believe that as a scholar of etymology (note his timely editorial in Cadernos de Saúde Pública on the etymology of "health"), Almeida Filho should consider that one cannot heedlessly conduct a semantic demarcation of doença as the equivalent of "sickness", relating to the collective realm. Doença [as disease] is consecrated not only by common sense, but by the biomedical literature. The Portuguese-language term doença originally comes from the Latin dolentia, which in turn comes from dolere, to hurt [or to grieve, as in the English dolent - T. N.]. In this case, Gadamer's argument is imperious, since pain is normally referred to at the individual level as being personal and inalienable, with a high level of "subjectivity".

The article was not intended to analyze in extensive detail the conditions for possible demarcation of "modes of health" or the respective "descriptors". Even so, at first glance, some specific aspects appear to demand greater clarification and elaboration. An example is the mode of health referred to as "1 - risk", something which, by the way, appears to be conceptually frisky [a play on words by the discussant using risco, or risk, and arisco, i.e., frisky or undisciplined - T. N.]... If epidemiological risks are measured and indicated by way of numerical values, what is the cut-off point which clearly defines which groups are actually at risk and which are not? How does one deal with the more elderly age brackets, increasingly present in the Brazilian population pyramids, where risks appear to proliferate with the expansion of vulnerabilities arising from aging?

It is appropriate to recall here that the discussions on risk extend beyond the strictly quantitative epidemiological approaches. The notion of "risk" is, pardon the term, proteiform, i.e., it can involve various aspects: economic (unemployment, poverty), environmental (various types of pollution), relative to personal conduct ("improper" ways of eating and drinking, not exercising), interpersonal (ways of establishing and maintaining amorous and sexual relations), and "criminal" (events linked to urban violence) (Lupton, 1999). All of these "risks" "ferment", mixing and overflowing into the cultural realm, becoming signs and symbols.

In short, the "experience" of risk plays an increasingly active role in the shaping of identity matrices and in the formation of subjectivities, prone to interpretations, amenable to approaches by SmpH. In this sense, SmpH descriptors are linked not only to the non-health category "sickness", but also to "risk" as "social perception". What name should be used for this category? (danger, threat? - and in Portuguese? ameaça, perigo?) Is it appropriate to baptize it? How does one deal with the antagonism between the "health feeling" - an aspect that assumes an "intimate, particular, private [mode]... which cannot be made public" and "health status", which seeks to "objectify the individual mode of health"?. Furthermore, how can one refer to something as a "descriptor" when it is considered indescribable, i.e., that which "cannot be made public"? Perhaps, at best, it may only be "describable" in literary or poetic terms, but this is not the realm of the current discussion.

Two further observations may be superfluous, especially since they relate to incidental comments in the essay:

Strictly speaking "Lakoff's prototypes" are not "Lakoff's"... In fact, this theory of categorization originates from the so-called "theory of basic level prototypes and categories" conceived by Eleanor Rosch and colleagues, as indicated by Lakoff himself (1987) in the study cited by Almeida Filho. Since the theory was presented very succinctly, clearly in keeping with the purpose of Almeida Filho's article, I will take this priceless opportunity to present a detailed description, given the relevance of these ideas (see Castiel, 1999).

As Almeida Filho states so well, there are circumstances in which no property, attribute, or characteristic is sufficient or necessary to define (in accordance with formal categorical logic) the case as belonging to the category. There are other modes of categorizing, based on criteria of familiar similarity, centrality, and prototypicality. These modes are anterior to the acquisition of logical-formal thinking. Such ideas were developed and systematized by the linguist Eleanor Rosch (1978) and colleagues in a general theory, based on empirical studies that challenged the classical point of view of categorization.

According to the formal/classical theory, no member of a category holds any primacy over others, since the aspects that define elements belonging to a given category are shared by all the members. Rosch (1978) showed in studies on the categories of color in the Dani language in New Guinea, which has two basic categories of color (mili - for dark, cold shades and mola - for light, hot shades) that there is an inclination or trend by individuals to choose given examples of the mola colors. In other words, they are considered prototypical - more representative than the others. In other words, there are asymmetries (prototypical effects) between members of the category and asymmetrical structures within the categories. Another example: in relation to the "bird" category, studies have shown that individuals indicate canaries and chickens as more representative of the category than penguins and ostriches.

It is important to emphasize that the categorical structure plays an essential role in the processes of reasoning and constitution of concepts. Under many circumstances, prototypes act as various types of cognitive points of reference and form the basis for inferences.

There also occur what are called "basic level effects" (Rosch, 1978). That is, there are levels that are more intelligible and prone to conceptualization than others. For example: basic level categories tend to be perceived better - "snake" is grasped better than the hierarchically superior level "reptile" or the subordinate level "pit viper" or "boa constrictor".

Ferreira (1996) conducted an investigation that attempted to determine whether the theory of prototypes and centrality could be verified in samples within the Brazilian context. His results corroborate the consistency of the work by Eleanor Rosch's group.

There is evidence that the categories we erect are heterogeneous, beginning with their cognitive origins. Human capacities to determine them are relational and also depend on our history of reciprocal effects with the world, that is, they simultaneously involve an interacting multiplicity of biological, cultural, and social elements. Categorizing skills appear more objective and accurate when referred to the basic level.

In short, categories depend on the ways in which individuals act with objects - how they perceive, construct images, organize information, and behave in relation to them. Basic level categories thus possess different properties from the others. They are amenable to characterization by means of images or motor actions. For example, the concept of "chair" is easier to conceive than that of "furniture" (Lakoff, 1987).

It is important to highlight that fuzzy logic as originally developed by Lotfi Zadeh does not exactly consist of an alternative logic that goes beyond the categorical logic that presides standard set theory. In broad terms, Zadeh (1965) conceived an ingenious perfection of standard set theory to model categories that allow for gradation - even describable by continuous "variables". In a classic set we have dichotomous aspects (either one is inside the category - 1; or outside it - 0); in a fuzzy set, as defined by Zadeh, it is possible to consider intermediate values between 0 and 1. Thus, the Rosch prototype theory does not appear to me to be amenable to immediate understanding by such logic, as Almeida Filho suggests.

The most recent edition of the standard Brazilian dictionary Aurélio (1999) presents the definition for "obverse" in the realm of logic as something resulting from obversion, that is, "a valid immediate inference for any type of categorical proposition obtained by changing the quality of the proposition and replacing the predicate with its complement. Thus all S is P, by obversion, will be no S is non-P". We can thus "push the argument" and obversely commit the following "deduction": if all health is the absence of disease, no health is thus the presence of disease?! One clearly perceives the weakness and impropriety of this proposition. This proposition of the reductio ad absurdum type illustrates an improper exercise in formal logical reasoning in the field of health and life, which should be used with extreme caution, since the results may be fallacious.

In a word, the purpose of this commentary was to emphasize that along with the progression in attempts to provide intelligibility to our objects of study, we should consider the possibility that there may be unattainable dimensions in this rationalist thrust that are proper to contemporary Western thought. For example, what is the "precision" that can be reached by linking "planes of emergence", "categories of non-health", "modes of health", and "descriptors" within these labyrinthine domains that may perchance be health (whether in the singular, or in the plural, as "healths"). If it is necessary (insofar as possible...) to make our objects of study more precise in order for the rationalist device to work, how should we proceed when we fail to achieve any clarity or precision in distinguishing all these items?

Furthermore, how do we know, in our quest to demarcate objects, when we produce not object-models but create object-artifacts and reify and fetishize them? It is hard to say, I admit. Yet even agreeing partially with Almeida Filho that "it is up to us to proceed", it appears to me to be appropriate to question, gently and carefully, how much good it actually does us in terms of advancement in health knowledge and practices to pursue our impetus forward... I believe there are moments in which one should take a brief "puzzled pause" to attempt to get some idea of the effects/results of our irrepressible drive to know and produce objects. On such occasions, even with some resistance, it is important to consider being penetrated (slow and easy, mind you) beyond a hint of doubt...

CASTIEL, L. D., 1999. A Medida do Possível. Saúde, Risco, Tecnobiociências. Rio de Janeiro: Editora Fiocruz/Editora Contracapa.

FERREIRA, A. B. H., 1999. Novo Aurélio Século XXI: O Dicionário da Língua Portuguesa. Rio de Janeiro: Nova Fronteira.

FERREIRA, M. C., 1996. Estrutura interna de categorias semânticas e seus efeitos no processamento cognitivo. In: Psicologia e Mente Social. Construção de Teorias e Problemas Metodológicos (S. L. C. Fernandes & M. Castanheira, org.), pp. 127-143, Rio de Janeiro: Editoria Central da Universidade Gama Filho.

LAKOFF, G., 1987. Women, Fire, and Dangerous Things. What Categories Reveal about the Mind. Chicago: University of Chicago Press.

LUPTON, D., 1999. Risk. New York: Routledge.

MOLES, A. A., 1995. As Ciências do Impreciso. Rio de Janeiro: Civilização Brasileira.

ROSCH, E. & LLOYD, B. B., 1978. Cognition and Categorization. Hillsdale: Lawrence Erlbaum Associates.

VALÉRY, P., 1998. Introdução ao Método de Leonardo da Vinci. Rio de Janeiro. Editora 34.

ZADEH, L., 1965. Fuzzy sets. Information and Control, 8:338-353.