DEBATE DEBATE

Health as a scientific object and a theme for life

Almeia Filho's essay For a General Theory of Health: Preliminary Epistemological and Anthropological Notes is surprising because of the level of intellectual energy with which the author launches into such a complex and difficult-to-define terrain, especially because he proposes to enter into the merit of defining a theory. Yet to construct a theory means first and foremost to believe that it is possible to explain or comprehend a phenomenon and the processes by which it is realized. It is this major undertaking that Almeida Filho embraces, surmounting the first difficulty by seeking to differentiate what might be called a Unified Theory from a General Theory.

Despite the inestimable value of the author's contribution for those who construct the theoretical practice of health, I see his work as an initial or preliminary approach, as he himself states it. This, because to construct a theory corresponds to the design of an organized system of propositions that are logical constructs and guide data acquisition and analysis, like the elaboration of concepts that are cognitive, pragmatic, and communicational artifacts bearing the theory's meaning. Beyond this, the idea of constructing a theory by constructing an organized whole has generally been applied more to the universe of disciplines and to the elaboration of schools of thought. To date, health has never been treated as either a discipline or school of thought, but rather as a field of knowledge and practices, within which there is a quest for scientific authority, technical capacity, and social power (Bourdieu, 1975); or as a living laboratory involving persons, equipment, experiences, roles, and strategies. (Latour & Woolgar, 1979). In this sense, I consider it quite problematic to formulate a theory of health or health models. It is a different matter to theorize the health concept, which is ultimately the article's attempt.

At any rate, the paper corresponds to the discussion and to the enunciation of a possible theory, which leads us to ask whether the author intends to reflect on the health theme as a differentiated discipline. It behooves Almeida Filho to provide us with another act of his creative energy, tackling the challenges of delving deeply into the constitution of this general theory. This is crucial, since as one utilizes a set of logically related propositions, such a theory must provide an order, a system, an organizational framework for thought, and its articulation with concrete reality, in an attempt to be understood by a community which follows the same path of reflection and action.

The concept-making undertaking is highly important and meritorious. The author presents a vast bibliographical review, ranging from seminal texts to contemporary studies, which he uses to relativize, challenge, or reaffirm the classics. And by blazing this intellectual trail, Almeida Filho helps shed light on the object at hand, besides raising questions and hypotheses with great propriety and tracing a spiral path to the conclusion, which was the beginning of his queries, relativizing his own ideas. I confess that I am curious to see the sequel to the scientific construction of theory, since it differs from the limited line of what has been conceived to date in sciences (including the social sciences) concerning general theory.

I would like to raise several questions based on these initial observations. The first is that from the very beginning of the paper, in my opinion, Almeida Filho falls into a theoretical trap when he identifies as structuring dimensions of the scientific field of health "the socio-anthropological dimension and the epistemological dimension". I ask: is the epistemological dimension structuring or is it part of the meta-analysis of theories? On the other hand, when he says that "despite recognizing its importance and founding role, the biological dimension will not be covered here, except insofar as it proves indispensable to clarify some specific issue in the health-disease models analyzed herein", is the author not losing a basic structuring dimension of the biological/social hybrid?

This is so true that the entire paper is permeated by the discourse on the biological, on phenomena and processes of falling ill, even when they appear in the widely varying semantic connotations presented by the author. What I am saying is that it becomes impossible to theorize about health/disease without dealing simultaneously with aspects of the biological/ social hybrid. The exclusion of one element from the dyad jeopardizes the discussion.

There is one further problematic point in the path chosen by Almeida Filho, namely the fact that the texts on which the author bases his essay are the results of a long-standing, firmly based, and sophisticated reflection by the so-called Anglo-Saxon (especially North American) school of medical anthropology and sociology. The fact is that since their birth, these disciplines are firmly linked to knowledge of diseases, to the point that the term "health" follows in the wake of such knowledge and is thus launched into a reductionist semantic spectrum whose center is the attempt to avoid risk and maintain a vision of normality. Almeida Filho's paper itself, intended as a preliminary thrust towards a theory of health, fails to escape this theoretical entanglement, leaving until the end a slightly more open discussion (albeit still not systematized) based on the ideas of Canguilhem, Ricardo Bueno, and Samaja, together with some rather succinct observations on Kant and Gadamer, the latter emphasizing health at the individual level.

I do not know if I can contribute, but based on my theoretical reflections I will highlight two points. One pertains to the differentiation between the notion of health as a total social fact (Mauss, 1974) and the notion of health as a concept dealt with by a specific sector, constituting itself as a field of theoretical and health care practices and policies.

In the former case, health constitutes the core of human experience in society in its essential expression, since it means the synthesis of well-being, individual and social quality of life, cultural forms of preservation of existence and the species, and above all, collective efforts and disputes by differentiated social groups to establish parameters for what it means to be healthy. Obviously, as Almeida Filho recalls, within any society this mater-notion is constructed (by its intellectuals and institutions) through the interpretation and reinterpretation of the socio-political and existential processes of the entire society, through interactive dynamics. Lévy-Strauss (1967), studying primitive communities, noted that the well-being and pain we feel are socially constructed. In this sense, health is a good: social and collective; it is a social and political conquest; it is an expression: cultural and moral. This great Gift, which the poor confuse with wealth and the rich go to great lengths to make eternal, even defines a society's level of development and denotes the entire inter-play of its internal forces to achieve what are considered ideal parameters.

Indeed, to conceive of health from this point of view allows one to glimpse it as an object of knowledge linking biology both to anthropology and to specific policies or economics. In this world of life, health is not confused with the opposite of diseases, because the person can have specific problems affecting his or her body or mind and consider himself or herself healthy. Disease can mean a privileged moment in life to achieve new healthy forms of growth and transcendence of personal limitations. In this regard it is important to quote Oliver Sacks, this amazing neurologist who devoted his life to exploring the world of the so-called "abnormal", who in the foreword to his book, An Anthropologist on Mars, states that "I am led to believe that it would be necessary to redefine the concepts of health/disease to view them in terms of the body's capacity to create a new organization and a new order, adequate for its special disposition and modified according to its needs, rather than referred to a rigid 'norm'" (Sacks, 1995:18). Stated differently, health cannot be confused with complete well-being as proposed according to the classical definition by the World Health Organization or with normality or absence of disease, terms that govern medical logic. Disorders and diseases may have the paradoxical magic of revealing latent powers, displaying a creative wellspring, both individual and collective. While they can destroy pathways, they can also reveal new forms of transcendence unimagined in their absence. Hence the study of health is a topic delving into the complexity of organization of life and vital processes.

With regard to the concept of health as dealt with in health care and the theoretical practice of health, we fail to escape from the chalk circle of the biomedical paradigm, in which medical anthropology, collective health, and the entire medical system are enmeshed.

Thus Almeida Filho's paper merits great praise as part of an effort by numerous authors to unshackle the concept of health from the imbroglio of prevailing medical ideology. This effort is all the more crucial because the rapid development of biology, the adoption of new life styles, and the quest for environmental adequacy increasingly demand that the role of health (which is much broader and more complex than that of medicine) be differentiated from the biomedical model. Hence, even when based on the epidemiological morbidity/mortality profile, health proposals will be in harmony with that broad notion that society defines as its essential level of healthy existence and its development threshold. In addition, health's role must be based on new theories of complexity that deal with the notion of a certain level of instability and imbalance - and not that of normality - as essential for a healthy life. It is imbalance and imperfection that allow the effort and increased capacity to transcend previous thresholds in both individual and collective life. To be healthy (or "to have health") will always be less to possess a state of normality and more to experience dynamics in existence that shift between disorder and order, from suffering to pleasure, from the capacity to maintain an identity to the quest for unexpected growth and evolution.

I am certain that by proposing to introduce a theory of health, Almeida Filho intends to encourage us to rethink the paradigms that are our birthplace. Thus, his essay is an invitation to redefine such paradigms, seeking an enhanced approach to the phenomenon/process that touches us so closely in our essential life and death dramas.

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LATOUR, B. & WOOLGAN, S. 1979. Laboratory Life. The Oral Construction of Scientific Facts. Beverly Hills: Sage Publications.

LÉVY-STRAUSS, C., 1967. Antropologia Estrutural. Rio de Janeiro: Editora Tempo Brasileiro.

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SACKS, O., 1995. Um Antropólogo em Marte. São Paulo. Companhia das Letras. b