DEBATE DEBATE

Almeida Filho's essay is stimulating, as indeed is all of his work. More than as a text, let us approach it, as proposed by Anatol Rosenfeld (1985), as a "pre-text", a pretext for dialogue, happenings, and creation. The "text" will be this construction in movement, this totality of arguments, intensities, and intention. So let us tackle the debate.

By proposing a discussion on the prerequisites for formulating a General Theory of Health, Almeida Filho constructs a chain of argument concluding that available readings on the health object/field/concept are incapable of transcending the negative view of "health as absence of disease" and are hence unfit to construct a "Theory of Health". Naturally, this epistemological architecture is not new, in fact it is a common pathway for those who attempt to overcome a hegemonic paradigm or paradigmatic references, i.e., to seek to demonstrate that the explanatory power of certain theories has grown stale and that it is urgent to surmount them. This demands a profound critique "from the inside", i.e., demarcating the limitations of that theory or discipline's tools based on its own logic. Unfortunately, in this case sociology was taken for one of its schools, that of functionalism, and its authors were "evaluated" based on the operational concepts they use, considered "revealing" of their adherence to the negative view of health. The article loses sight of the theoretical context of each author quoted in the process, the many other readings from the domain of "sociology of health" itself, and the analysis of sociologists incorporated into the Collective Health debate (like Habermas, Bourdieu, and Giddens, to cite just those best known to the general public) which have certainly expanded the health concept and health praxis well beyond the equation "health = non-disease".

According to the author, anthropology, as expressed by the watershed of medical anthropology, has advanced in the effort at conceptualizing the DIS complex (disease, illness, sickness), but has failed to overcome the essential problem of prioritizing the ill individual's return to functioning with a normal and healthy life, without entering into the issue of what this normality is or the concept of health implied therein. Again, the rich dimension is often reduced to examining the basic concepts, and when the author recognizes in certain authors (Young and Bibeau-Corin, for example) a tendency to retrieve historical totality, a link between "the micro and the macro", a synergy between individual action and historical/cultural structures, he appears to find a new undertaking which in fact has been a daily issue for discussion in the Social Sciences for at least twenty years. Since so-called "radical" phenomenology had great influence on the field of health in the 1970s and now returns in adulterated fashion under the veil of methodological imprecisions, empiricist spontaneity, and studies erroneously referred to as "qualitative research", one can understand the author's concern.

The "inability" to overcome the negative vision of health still prevails. However, perhaps it is not a matter of viewing health as "the mere absence of disease-illness-sickness", hence an absence in terms of what health is in fact. But would the issue not be to recognize that the human experience of health has adhered to (not only dialectically but "ontologically") the very clash, the very struggle against death and the fear of pain, suffering, and destruction? Not as non-disease but as the unceasing struggle both against maculae (sanus) and at the same time for physical, psychological, and cultural integrity (salvus) (Almeida Filho, 2000), meanwhile, always noting the historicity of this confrontation, since as mentioned above the historicity of the object is the reality principle of Social Sciences (Passeron, 1995). Once removed from this dimension, does the concept of health not become watered down? This does not indicate ignoring the need, identified so well by Almeida Filho's paper, to undertake a reflection that overcomes the view of health as the mere inverse of disease.

In fact not only sociology but also the social sciences (and the so-called natural sciences as well) are insufficient for an understanding/explanation of what health is, this polysemous and complex field/object. Still, as postulated, we run the risk of basing the discussion of this insufficiency (which is rich because it makes dialogue with other fields of knowledge indispensable) on an argument of incapacity, based on a rapid and external review of what these sciences are.

But the debate does not end here. It raises the bothersome question: is it possible to construct a General Theory of Health? And we would add to this: is it possible and desirable today to construct a General Theory? Many authors in Modernity have followed this enticing proposition, albeit in the form of a "unified theory". At any rate, therein lies the idea of a theoretical construct, hence a way-of-seeing, capable of explaining the concatenation/functioning/organization of a set of phenomena or of the social order itself. The so-called "total theories" that circulated in the 19th century and survived the 20th century articulated disciplinary knowledge and even provided a number of multidisciplinary propositions. They made an effort to translate, measure, and predict the complex, the future, and even the incommensurable. They achieved historical success, although orthopedically framing the real in reality; after all, they had at hand some certainties and the notion that the gaps in knowledge had already been identified.

Still, the paper's objective is precisely to distinguish itself from this mold: it does not propose a total theory, but alternative modes of understanding, respecting the complexity of the objects (hence there is not one health object, but various objects, shaped by the respective disciplinary perspectives) and the plurality of this scientific task with a problem which is by definition interdisciplinary.

The author courageously proposes to tackle other powerful obstacles that resist attempts at a General Theory. The basic dimension of any theory, the concept, reveals the challenge of preserving its totality and polysemy, meanwhile being "objectifying". It becomes necessary to discern in the word health what is defined as concept, object, object-model, and field, both with regard to the heuristic aspect and the socio-cultural practices imbedded in these definitions (which are not restricted to SmpH but connect to a sociology of knowledge).

Some doubts remain as to the intents and their mode of presentation/organization. A General Theory is proposed in which each field of knowledge plays a role, contributing with certain operators. Adhered to each other within this theoretical system, which is understood as open, would such distinct epistemic traditions be comfortable? Would the "descriptors" be the possibility of objectivity capable of equalizing or assuaging such radical differences as well as promoting a trans- or interdisciplinary dialogue? Naturally any theory must "semantically discipline" the words and concepts it employs (Passeron, 1995). But how does one avoid transforming such a proposition into the grammar of a formal system? How does one resist succumbing to the clutches of structuralist logic? Thinking out loud, how does one preserve the poiesis, so dear to the complex thinking we claim for the health field, if one implicitly determines disciplinary roles a priori?

Given the limited space for debate, I wish to conclude by saying how happy I am to be able to initiate a dense debate, made possible by such a challenging text by Almeida Filho.

Acknowledgments

My thanks to Eduardo Alves Mendonça with whom I had the good fortune of discussing this review.

ALMEIDA FILHO, N., 2000. Qual o sentido do termo saúde? Cadernos de Saúde Pública, 16:300-301.

PASSERON, J. C., 1995. O Raciocínio Sociológico. O Espaço Não-Popperiano do Raciocínio Natural. Petrópolis: Vozes.

ROSENFELD, A., 1985. Texto/Contexto. São Paulo: Perspectiva