DEBATE DEBATE

The analysis of the "point of departure" towards a general theory of health that Naomar Almeida Filho proposes is not only an urgent challenge for the scientific community, but a subject that demands the combined efforts of all the social forces now concerned with caring for and developing life.

The time is ripe, and the level of visibility has increased, not only because we are now better equipped with theoretical/epistemological arguments, but because the history of capitalist modernity has led to a rapid deterioration of rights and the loss of all support for establishing a general situation of health to respond to the expectations of society in general.

It is within this context that we should analyze the importance of the queries raised by the article discussed herein and the value of the critical inventory employed by our respected Brazilian colleague. It is in light of this great human need and the perplexities of a world submitted to extensive destruction in health that we ask whether it is now suitable and necessary to spawn a discussion on a general theory of health, precisely at a time characterized by a widespread questioning of "general scientific frameworks" and "meta-accounts" encompassing broad interpretations in fields of knowledge. And our answer is emphatically affirmative. Based on a profound and well-informed essay, Naomar Almeida Filho invites us into a timely and necessary debate. His article demonstrates not only his own maturity as an investigator and epistemologist in health, but also that of the entire Latin American Social Medicine movement, which has provided decisive contributions from various countries.

Beyond the possibility of adding new facets to Almeida Filho's analysis (and we are familiar with several such sources from Latin America that would doubtless enrich the purposive conclusion to his paper), we must acknowledge how correct he was in fueling the critical flame in the much-needed debate over a general theory of health.

The reading Almeida Filho provides us with on the problem, and that leads him to conclude with his proposal of "modes of health", begins and continues with a line of analysis strongly linked to the contributions from European epistemology, and therein lies both the strength and importance of his contribution, as well as its limits. The objective of my brief commentary is to outline this strength, as well as the limits, and highlight the need to incorporate other perspectives.

The importance of Almeida Filho's contribution can be grasped by retracing the logical cycle he follows, woven around a critical reading of various contributions from sociology, anthropology, and epistemology. The entire first section of his essay is devoted to displaying the inability of psycho-biological approaches to fully deal with the health object, due to their focus on individual disease processes and their negative view of health as the absence of disease, i.e., proposals constituted through functionalist sociology that distinguished between physical and perceived sickness with the goal of explaining sickness as the impossibility of performing personal and organic functions. He also questions the concepts provided by phenomenology, centered on the restrictive notion of health as the absence of perceived sickness. Hence the author's quest having turned towards the contributions of psycho-cultural anthropology, emphasizing the role of culture in constructing the notion of "sickness" (enfermedad) - through a shared language and the creation of "health/sickness/care" cultural complexes under the formula sickness = disease + illness (Kleinman), the study of the forms of ascribing meaning and the formation of semantic networks (Good & Good), or even the incorporation of social and power relations as determinants of the interpretative models for sickness as an attempt to surmount the micro-social (Young). Such approaches were also centered on the notion of sickness and curative practices. And towards the end of his critical inventory, Almeida Filho reviews the semeiologic approaches that attempted to overcome the micro-social limits of previous lines of analysis, incorporating the analysis of the relationship between semantic structures and hegemonic and power structures (Good), as well as the variants challenging excessive particular emphasis, proposing the need for a macro-social historical approach centered on the observation of structuring collective conditions and conditioning experiences that combine in systems of "signs, meanings, and practices in health" that do not obey Western medical logic and that appear as non-stable and diffuse prototypes (Bibeau & Corin). Almeida Filho recognizes that this latter view not only continues to be framed in the notion of sickness, but that it expresses a certain anti-naturalism that leaves aside the problem's biological material elements.

At this point our author launches into the quest for a veritable epistemology of health through an analysis of Georges Canguilhem's thought. He analyzes the French epistemologist's proposals of considering normality as a life norm that incorporates the healthy and the pathological, whereby health is not considered simply the obedience to a norm or model, since disobedience and deviation are part of health, and approaching the discussion of this free and unconditional "philosophical health" that is forged in physicians' praxeological scenario with their patients and is also projected into a public health linked to the notions of utility, quality of life, and happiness, a process that is finally realized in the phenotype and is observable. Almeida Filho recognizes the importance of a Canguilhemian opening towards a new epistemology, yet criticizes the premise that this vision is linked fundamentally to the biological, despite recognizing "that health is not only life in the silence of the organs... but also life in the silence of social relations" and that scientific health should assimilate aspects of subjective and philosophical individual health in such a way that it is not reduced to sickness and so-called "risks".

In short, through his epistemological tour, Almeida Filho has succeeded first of all in clarifying the inability of psycho-biological and psycho-cultural models to overcome the negative definitions and solve "Kant's problem" of this resistance against conceptualizing health in and of itself, and secondly in retrieving the potential of Canguilhem's opening, but signaling its focus on the biological terrain, just as Foucault's explanation was oriented towards merely social and discursive explanations.

In the final, purposive section, Almeida Filho turns to the contribution of Juan Samaja, with his idea of multiple determination with hierarchical interfaces, an important Latin American line of reflection that adds to other contributions that have opened the doors to an integral conceptualization.

Within these brief comments, we do not intend to develop a profound analysis of the "modes of health" proposals or its basis on the idea of hierarchical interfaces, since this merits elaboration that we are incorporating into other article. The point here is first to highlight the value of the pathway that Almeida Filho has called us to follow and the germinative potential of some of his ideas for epistemological work in the coming years. However, secondly, we are interested in identifying here some of the limitations of his approach, as well as an unresolved epistemological problem that is not visible in his analysis, despite its importance, namely, what he would refer to as resistance towards the collective.

Epistemology and history teach us that in Science, the processes of conceptual cleansing proposed from an emancipatory perspective are closely linked to the need for practical advances in collectives that develop their process in the midst of hegemony, are full of intentionality and conditioned by the horizon of visibility and their social contextualization, a horizon that depends extensively on epistemic conditions - in the Foucaultian sense - as well as the practical articulations of the scientific. In this sense, we ask whether the only "point of departure" or take-off in the critical process is the inventory of contributions from European thought, or if there is not a need to think out our own model and orient our reflections beyond this single point of view, within an intercultural construction and the perspective of critical multiculturalism.

While the construction of a scientific discourse on health in general is an academic issue, it involves intellectual work and a practice that go beyond the limits of academe, but which are part of the construction of knowledge.

To orient the current work, we need to clarify its nature, content, and direction, and this is not possible. At least from a democratic and integral perspective, this can only be done from the scientific community and based on a vision inspired exclusively by the cardinal problems and points of growth established by European epistemology, no matter how important the latter may be.

To establish what we are referring to when we speak of a general theory of health, i.e., what the difference is between a broad and innovative theory and a matrix, unilateral, and hegemonic account - and to analyze who we are calling on for such an undertaking, it is necessary to call other societal perspectives into the debate, and this is not only a logistic, practical problem, but also a theoretical one. Furthermore, from a praxeological focus, a general theory not only defines the object of transformation in a scientific field, but also the subject of said transformation, and the two go hand in hand, since they are interdependent elements of knowledge. Stated differently, we presuppose here that if a theory cannot be reduced to a reflection induced in thought, nor can it be a simple deduction of reality based on a rational model, then a general theory of health should encompass the historical subjects mobilized around the object as a field of action - in this case the field of health - both as the broadest of processes that constitute its complex object and with its hierarchical domains, with its macro-micro and social-biological articulations.

As Latour (1999) would explain metaphorically, the idea of a separation between the world (outside) and the mind (inside) that is present in the form of both positivist objectivism and that of rationalism and phenomenology allowed for the creation of the notion of an "objective world", unreachable for the common people below; and this false disjunction made it possible to impose the power of cold, scientific reason, outside of a human collective stigmatized as an irrational mass.

The construction of a new basis for a general theory of health that Almeida Filho calls us to reflect on cannot be achieved through this open or disguised polarization between the "subject", the "objective world", and the "mass", but from a praxeological view that dissolves such a polarity and recovers the human side of scientific practice and its profound relations with the collective. As expressed by the Scientific Institute of Indigenous Cultures of the Confederation of Indians of Ecuador, it is part of the struggle for "diversity with equity... within a context of political democracy, social justice, and economic equality" (ICCI, 2001), the urgency to construct life and health as an antithesis, which are expressed outside the world of academe and form the best interpelation concerning the meaning of science.

ICCI (Instituto Científico de Culturas Indígenas), 2001. Editorial. Boletín ICCI-RIMAI, 24.

LATOUR, B., 1999. Pandora's Hope: Essays on the Reality of Science Studies. Cambridge: Harvard University Press.