DEBATE DEBATE

My first comment is how current, relevant, and broad is the theme discussed by the author: the absence of a General Theory of Health in this interdisciplinary field of scientific production and intervention which until recently was called Social Medicine or Public Health, and which we now quite significantly refer to as Collective Health. One should also emphasize, at least in the conceptual terms in which the author situates his analysis, how unique his treatment of the topic is, as far as I know, especially in its original area, that of Epidemiology.

The second comment is that the theoretical "vacuity" referring to a positivity of health is present as demonstrated by Almeida Filho, not only in Epidemiology, the object of a previous study, complementary to this article, but also in the very field of human sciences focusing on the health-disease process in society and culture. Utilizing the basic categories present in this field (disease-illness-sickness) and related ones, conducting what he terms a semeiologic analysis, the author develops an extensive, intense, and erudite discussion with the main Anglo-American schools of thought in the fields of medical sociology and anthropology, subsequently delving into the main lines of contemporary epistemology.

As a third comment, I wish to emphasize that this conceptual and theoretical "void" is linked primarily to the predominance of the biomedical frame of reference in the social sciences (as the author demonstrates) vis-à-vis phenomena related to discomfort, suffering, and the loss of health and life by individuals, groups, and communities. What predominates in this frame of reference are categories that objectify pathology, disease, infirmity, as well as pairs of opposites such as normality/abnormality, ability/disability, etc.

But the predominance of such categories is also presented (and here I begin my fourth comment) in culture and in basic social relations as a whole in contemporary society, becoming, for the subject, a storehouse of meanings in relation to the aforementioned phenomena.

Hence, the "objectivity" of such phenomena also becomes "subjectivity": the various subjects come to perceive and feel the loss (or the preservation) of their vitality "by the books", i.e., as established in normative terms by society and its institutions. The establishment of meanings in the scientific disciplines, whether from the biomedical or social field, is not disconnected from the historical development of modern society (quite to the contrary), from the establishment of institutionally "valid" meanings for the subject.

Parsonian functionalist sociological thought was unsurpassed in perceiving and giving form to this imbrication between vital order and institutional order in modern societies. It was no coincidence that the key category in Parson's thinking was that of social order, allied with the central concept of social system. However, this imbrication has affected social thought since the 19th century and is at the central constitutive thrust of the human sciences, as highlighted by Foucault in his Les Mots et les Choses, and can be flagrant in certain aspects of the work of Durkheim, of whom Parsons is a professed disciple.

The issue of social order (and hence that of deviation) identified with the polarity of social normality/disorder (or disturbance), and the latter indirectly with the life/death polarity is a key point in the identification of sickness/disease with vital disorder and of the latter with the indirect identification with the polarity order/normality, and disorder/deviation/disease in social thought. This set of identifications is already present in Comte, is assumed by Durkheim, and is transmitted in terms of a theoretical lineage to functionalist thought.

From my point of view the central issue in this set of identifications which "expels" from its theoretical nucleus such positivities as health, life, or vitality is the institutional issue, or more explicitly, the issue of institutional order in which is immersed the thought of both disciplinary fields (biomedical and social). Although the effort at grasping "subjective meanings" - or those linked to subjectivity in relation to phenomena ranging from sickness to death, or from recovery to cure - seeks a place in some phenomenological or vitalist formulations, the issue of order and deviation (and its necessary discipline) remains at the epistemological core of grasping these phenomena in the modern episteme, as demonstrated by Foucault. In this case, how does one secure the theoretical positivity of health, the author's great quest in the article at hand, through the idea of a unified theory of health?

From my point of view, theoretically securing a positive conceptualization of health assumes the epistemological and institutional deconstruction of the disease-illness-sickness order, i.e., in the final analysis that of the medical order.

French socio-anthropology (Dupuy-Karsenty, Boltansky, Herzlich, and Pierret, among others) has worked extensively in this direction in the last thirty years. To be sure, it was not the object of the author's analysis, but it provides an important contribution in the sense of considering this necessary "deconstruction". On the other hand, Bourdieu's sociological thought offers interesting theoretical clues with the categories of field, habitus, and practice, in the sense of considering the origin of the theoretical void on health in the biomedical and social fields.

Finally, as a fifth comment, by way of posing a question, I wish to address the proposal of a unified theory of health. First: is it possible? General theories assume solidly established disciplinary fields, with unquestionable "root" concepts (although discussed in terms of their content or interpretation), which is certainly not the case of collective health.

Second, is it desirable? In the life sciences or social sciences, when a unified theory has been proposed, it has traversed biology as the unifying basis, which ends up incorporating a far-from-desirable set of deterministic and valuative propositions. I believe that in this case it is better to firmly prioritize basic concepts providing a positive basis for the health issue, to base it on a set of complementary theories that the functionalist Merton (Social Theory and Social Structure) called Theories of the Middle Range. Perhaps it might be a matter of conceiving a "grand theory" in collective health as a theoretical finishing line and not as a point of departure.