DEBATE DEBATE

In defense of a creolized grammar of the health-disease complex

"The culture of any society at any time is more like the debris, or fall-out, of past ideological systems, than it is itself a system, a coherent whole. Coherent wholes may exist (but these tend to be lodged in individual heads, sometimes in those of obsessives and paranoiacs), but human social groups tend to find their openness to the future in the variety of their metaphors for what may be the good life and in the context of their paradigms" (Victor Turner, 1974:14).

The perspective I favor in my response to Professor Naomar Almeida Filho borrows first from work in the anthropology of science produced by Latour (1999) and Hacking (1999) and second from my own experience as a researcher in the area of medical anthropology, a sub-discipline that emerged from studies conducted primarily in non-Western societies during the colonial era. In those days anthropologists were busy portraying particular beliefs (witchcraft, sorcery, magic) invented by people to explain misfortunes, disasters, and diseases, and describing therapeutic rituals (spirit possession, magical devices, anti-sorcery ceremonies) that healers applied to treat particular episodes of the disease-illness-sickness complex. Few anthropologists have shown a keen interest in developing an anthropology of health as a counterweight to the "disease perspective" canonized by classical medical anthropology. Only recently have anthropologists begun to consider the issue of health and well-being as a topic which deserves full attention. The essay by Professor de Almeida Filho is a timely contribution from which medical anthropologists should greatly benefit.

I begin by briefly stating my stance as a medical anthropologist. In my view, humans in all societies are confronted with the same fundamental "existential problems" and "anxieties", like the awareness of the inevitability of death (mortuary rituals and after-death cults to the departed), the origins of evil, suffering, and disease (magic rituals, religious ceremonies), and difficulty in maintaining harmony, cooperation, and well-being. Human societies responded to these challenges by combining two series of representations, ideas, and practices: (a) a symbolic idiom built around basic mimetic (metaphorical and metonymic) processes which helped them assign meaning to their afflictions and (b) an empirically-oriented attitude that eventually gave birth to what we now call science. Ritual healing practices have developed at the interface between the symbolic idiom and the pragmatic effort to tame the "bad" via the use of plants, curative interventions, and other reparative techniques. Throughout the millennia, the search for meaning and the drive for knowledge have served as points of departure for further theoretical elaborations in the various cultures which all ended up inventing their own therapeutic systems, among which one finds Western medicine.

I agree with philosophers and historians of science who have amply demonstrated in recent decades that scientific facts, theories, and concepts are value-laden and that medical, psychological, and socio-anthropological knowledge on either health or disease is culturally and historically constructed. Experts in the ethnography of science have shown that all forms of knowledge are largely context-dependent products rather than transcendent realities, and that the prevalent Western literature in contemporary biology, medicine, psychiatry, and health-related social sciences tend both to bring particular theoretical frameworks, categories, and models to the forefront and to suppress or silence alternative ways to assess, interpret, name, and theorize certain areas such as the health/well-being complex. Meanwhile, critical social scientists insist that the production of knowledge is never neutral, that there is no such thing as a "mere fact" or an evidence-based theory, and that scholars, intellectuals, and theory-builders themselves are inevitably linked to a particular ideology or set of beliefs.

By combining a socio-anthropological dimension with linguistic, semantic, and epistemological considerations, Professor Almeida Filho has established a solid foundation for delineating a theory of health which incorporates all major elements put at work in the double strategy, namely the beliefs systems and the scientific response to which humans resort wherever and whenever they face misfortune, disease, and other sorts of problems. I enthusiastically support the line of argument proposed by Professor Almeida Filho in his challenging essay. To organize my own thinking about what a theory of health is, I found it useful to explore five areas: the "perfect health" ideology; biology as a historical and interpersonal script; humans as producers of languages and idioms of health-distress; the life of people in multiple worlds; and local epistemologies. I feel that all these five domains should be considered as necessary and complementary sources in the theorization of the health domain. I conclude my own questioning by asking whether there is room for theory in modern science. The path I decided to take leads exactly where Professor Almeida Filho was heading: concentrating on health rather than disease and introducing local epistemologies in the construction of a general theory of health.

The quest for "perfect health"

The "well-being complex" has been installed as a key symbol in Western culture, particularly in countries of the Northern hemisphere: techniques of all sorts and a rhetoric of persuasion (e.g., from body massage to religious enrollment) are currently used to discipline the body and regulate individual life styles. In certain contexts, the therapist-patient relationship has also been transformed into a continuous and long-term relationship for body management (clinical surveillance or regular check-ups to verify the results of treatment), giving rise to a growing "care industry" which has colonized the health domain by medicalizing social and psychological conditions which have to do with the very fact that a person exists. One can easily find multiple examples in both industrial nations and the developing world of medical technologies aimed at controlling deviant behavior (hyperactive children, drug addiction, etc.), as well as plagues, diseases, and even natural life cycle events (childbirth, menopause, etc.).

Such heavy reliance on healing techniques for the body and mind reflects one of the central concerns of our era: the achievement of a "perfect health" status. The pharmaceutical industry spends billions on research into treatments for such problems as obesity and overweight, baldness, wrinkles, acne, depression, and impotence, leading to a "life style drug market" that induces people to fantasize about the perfect body, mood, and mind. All this reinforces people's dependence on "experts" of various vintages and on the multiplication of medical techniques geared to reestablish equilibrium and repair the body-mind complex.

In the past, medicine's role was to heal the human body from sickness. In our age, medical technologies aim to do much more: modern medicine is, intentionally, total recovery, organ transplants, cosmetics, and self-help rehabilitation. While modern medical technologies can effectively cure the sick body, it also claims to alter the body and mind in such ways as to improve performance, preserve youth, achieve immortality, reduce or eliminate gender differentials, and eventually reach the utopia of "perfect health". Based on these premises, prevention has become a massive technological enterprise, often involving sophisticated and costly genetic prediction procedures, and reinforcing dependence on scientific technologies, but also creating more ethical dilemmas and growing contradictions.

Biology as a historical and interpersonal script

We have entered an era dominated by a new biology that links the brain-mind complex to environment and history, both at collective and individual levels. The schism introduced in modern biology by Descartes' dualism of mind and brain has been thrown to the wind: new ways are emerging to perceive the body, the mind, the emotions, and the health-disease complex. The mechanistic philosophy which used to see the body as a machine is visibly dead (or dying): contemporary (neuro)biology is based on the indissoluble relationship between the person's life experience and the modeling of his/her biological memory, the historical shaping of individual neurological architecture, the coding of neural networks along with one's personal history, and the bio-psycho-social dynamics of higher consciousness. Biology is thus seen as dynamic, interpersonal, historical, and evolutionary. Individual experiences constantly inform the biological networks and provoke rapid and ever-changing patterns in the neurological codes. Individual histories shape brain and mind simultaneously; the brain and mind are indissolubly linked to each another and to the person's actual history.

Neuroscientists, evolutionary psychologists, and biological anthropologists generally agree that individual neurological maps are both historically and environmentally produced. Neural codes are formed through: "une mise en correspondance entre, d'une part, un état de choses extérieur, un objet, une situation, et d'autre part une organisation neuronale et l'état d'activité qui l'investit" (Changeux, 1998: 113). Thus, differences in the epigenetic development of persons (particularly in the family environment) contribute to differences in the organization of each individual's biological architecture. It is true that the more we know about the interactions between genetic and non-genetic factors, the more complicated these interactions appear to be: the ways in which "causation" functions are often far from self-evident, and a number of feedback loops, both positive and negative, are constantly at work. The accepted explanation of "causation" from genes to culture, as from genes to any other human phenomenon, is neither exclusively hereditary nor exclusively environmental: it is interaction between the two. This is also common knowledge among people in most cultures around the world.

Nevertheless, the "historically-grounded biological model" has weaknesses: it discards what people do with what they produce, the meanings they attach to their local productions, and the experiences they construct. It is not surprising that scholars who examine human phenomena from the perspective of persons consider the "historical script" in biology to be reductionist, animal-driven, and still excessively deterministic, despite its effort to overcome past dualisms, like that proposed by Descartes. Undoubtedly there is still significant misunderstanding between historically and culturally minded biologists and social scientists, but much has been done to narrow gaps from the past. It is now possible to move beyond the past opposition to establish solid, balanced cooperation between the socio-cultural and biodynamic paradigms, in a partnership in which both perspectives are equally valued and respected. Professor Almeida Filho adds to this line of thought a strong interest in the meaning-based and experiential dimension of the health-disease complex.

Humans as producers of languages and idioms of health-distress

Language is the function that characterizes the species (Homo sapiens sapiens) as distinct from precursor primate systems of communication: it is emblematic of a universally structured human mind, the same in all places and times. Chomsky has demonstrated that all human languages share certain universal features, both at the syntactic level of grammatical categories and at the phonological level of sounds. He argues that there is a Universal Grammar which is linked to the fact that humans are equipped with the same innately programmed capacity for language, representation, and symbolization. Like the complexity of language itself, the capacity to represent (signifier-signified) and to symbolize (minimally the mimetic faculty) is seen as being intrinsic to the neurological organization of the brain and to the functioning of the mind; in parallel, representational and symbolic capabilities are said to be linked to the linguistic ability that defines human beings. One may draw two conclusions from these observations: (a) probably beyond all these phenomena, there exists a meta-structure (consciousness?) which is thoroughly organized in the form of a language; (b) all other physical, mental, and symbolic capacities are also constituted as built-in programs and may thus be seen as translating this same linguistically-shaped meta-structure.

Human beings build diverse and sophisticated cultures. Contrary to non-human primates, human beings are not only equipped to produce language: they actually speak one (or many) language(s) and assign meanings, generating multiple narratives and stories on the basis of the grammar(s) they master. In addition to languages, human groups invent myths and cosmologies which provide blueprints to interpret the world in which they live, ideologies, belief systems, and moral norms which tend to vary (probably around a universal core) from society to society as well as particular social rules (family patterns, inter-group relations) which serve as a foundation for constructing the ways "to be a person" in a given society. All these ingredients compose what anthropologists refer to as a "culture". Our modernity is constituted, as any other culture, as the ensemble of narratives, stories, and experiences that people generate on the basis of the values, norms, symbols, and myths shaping the contemporary world.

In their study of narratives and experiences produced by individuals, many social scientists in recent years have adopted an interpretive and phenomenological stance which borrows much from semeiology, literary criticism, and European existential phenomenology. Merleau-Ponty was one of the leaders in the post-war industrial world of a movement to renew philosophy - initiated by Husserl with phenomenology - that involved a new relationship between body and mind, a topic that had remained unchallenged since Descartes. Merleau-Ponty's phenomenology does not envision the body-mind as a duality, nor as a dichotomy, but rather as the translation (expression) of a "double nature": corporeality returns here in the form of a vehicle, leaving room for meaningful experiences that persons are able both to live and to put into words. Discourses, narratives, and complaints that persons phrase to express their emotions are inevitably shaped by the idioms provided by the culture(s) to which they belong.

For several decades social scientists have argued against all sorts of reductionist theories that attempt to model the study of persons and human cultures (including human health) on an animal model. They have reminded their biomedical colleagues that the problem of signification (meaning) is tied to human beings' self-definition and that the practice of human sciences thus requires the inclusion of semeiology and hermeneutics. Human beings are ontological beings who cannot avoid interpreting themselves, others, and the world. "Human beings are self-interpreting animals", anthropologists write repeatedly, echoing a central theme in contemporary social sciences.

I firmly believe it is important, as Professor Almeida Filho does in a convincing way, to examine specific interrelations between collective meaning systems, local idioms of health-distress, and individual discourses of well-being and pain, that is, to know how people experience and express emotions and how they connect somatic symptoms with their inner psychological states. This requires a critical review of past and current hypotheses of how symptoms are produced, constructed, and experienced by different peoples or cultures under varying social, material, political, and psychological conditions.

To date, research on idioms of health-distress has emphasized the ways such idioms are shaped by cultural taxonomies, explanatory models, and popular semeiologies, at times neglecting the social context in which the person lives and the person's spatial position - in many cases - at the boundaries between multiple cultural worlds. Anthropologically-minded psychiatrists and psychologists also favor elements within a person that can be connected to categories such as "symptom schemes", "illness schemes", and "idioms of distress".

Besides meaning, two other important notions, namely narrativization and experience, are attached to the perspective opened by the phenomenological and interpretive turn of medical social sciences. It is not enough to say that people act towards things in at least partial congruence with the meanings these things hold for them. People also produce discourses, commentaries, and narratives in which they tell, via complex rhetorical strategies, the meanings associated with their experiences and behaviors. Their idioms of health-distress and their health-illness explanatory models and schemes are also largely dependent on their systems of meaning. To be properly understood, the various narratives and idioms have to be inserted within a series of other discourses and ultimately placed in the larger context of the culture which supports these texts. We must take into account the fact that human speakers incorporate cultural presuppositions into their narratives, that the blank spaces of discourses are loaded with meanings, and that any reading limited to the surface runs the risk of missing the cultural dimension. The stress put on narrativization is sometimes so strong in contemporary medical social sciences that some scholars, particularly medical anthropologists, have come to see culture as nothing more than a mega-text.

People today stand on the boundaries of many worlds

In almost all modern countries, one finds the coexistence of multiple languages, religions, and cultures. The dialectic notions of center and periphery, inclusion and exclusion, majority and minority are commonly used by social scientists to study the dynamics of cultural power, cultural pluralism, hegemony and dominance, control and submission, and the relations that either oppose or link the various social groups in a given society. Most people today live on the boundaries between groups and define themselves as persons with multiple affiliations. It appears particularly urgent to tackle the challenges created by the impact of such pluralistic societies (many religions, languages, and cultures) on both individuals and families. Cognitive maps, values, and systems of meaning are reorganized to fit the pluralist context, with vacuums and cracks in their midst. Recent research frameworks take into account the contradictions and tensions emerging from the pluralistic situations in which individuals and groups live. Creolized versions of cultural systems have emerged on all continents, and citizens of most countries are therefore torn between multiple parallel attachments, while people everywhere are trapped between fidelity to one's cultural identity and the need to assume a more flexible pluralist frame of reference (Bibeau, 1997).

The ethnic, linguistic, religious, and cultural pluralism which was already present in the vast majority of countries is greatly accelerated by migration, displacement, and refugee movements across national borders and by the fact that countries are increasingly permeable to influences from abroad. In most countries, people are forced to confront more and more ambiguity, with multiple group affiliations and hybrid identification models at the edges of their cultural worlds. The dominant challenge in all pluralist societies is to build collective cultural reference systems that combine the local with the global and community-grounded values with a common sense of belonging.

In their comments on the interpretive turn that human sciences have taken since the mid-1970s, Rabinow & Sullivan (1985:35) wrote: "Common meanings are the basis of community. Inter-subjective meaning gives a people a common language to talk about social reality and a common understanding of certain norms, but only with common meanings does this common reference world contain significant common actions, celebrations, and feelings. These are objects in the world that everybody shares. This is what makes community". Inter-subjective meanings are not only located in the minds of people, but are also incorporated and expressed in their collective practices and constituted as social actions. Only a direct experience of the world of others provides a sense of pre-comprehension about the meanings people attach to their behaviors and actions. This implies that researchers must become familiar with the world of others (natural settings) and experience it at least partially if they want to be able to grasp something of the world in which people live. All this becomes more complex when people start living in multiple parallel worlds as in contemporary societies.

Local epistemologies as a source for theorizing

We know that indicators (markers, signs, symptoms) used by people to identify actual health problems as well as lay explanatory systems do not exist as explicitly conceptualized bodies of knowledge that can be easily reconstituted and transformed into a sort of textbook of "popular pathology". Such knowledge is rather enacted and manifested in the actual behaviors of people (patients, families, community groups) when they are faced with concrete cases. I feel that any exploration into theory in the health-disease complex must consider at least the following three series of data: (a) the local representations, ideas and practices developed to see the world, to be a person, to conduct a valuable life, to produce well-being, to organize time and space, and to relate to material progress; (b) the indigenous values related to the body-mind, to the health-disease complex and to the spiritual aspects of human life; and (c) the knowledge regarding the natural, physical, and social as well as psychological, spiritual, and cultural dimensions of the world in which individuals and groups live. Professor Almeida Filho's theorization of health and disease is precisely based on a comprehensive approach that includes social and cultural traditions as well as local systems of knowledge.

Ordinary people have learned that responses provided by health professionals and "experts" cannot suffice to alleviate their problems and that sustainable solutions require alliances between locally-based interventions and professional actions and, more globally, a true integration between the values and practices of people and formal professional practices. Locally produced, collective healing responses have a greater chance of matching the needs and actual problems as experienced by individuals and groups. As a note of caution, however, while I acknowledge the relevance of such community-based lay knowledge, I should also recognize its own constraints and limitations. Professor Almeida Filho is, I think, on the right track when he looks for an implicit theory in the different systems of signs, meaning, and practices.

Is there any place for theory in modern science?

Professor Naomar Almeida Filho is aware, probably more than anyone else, that modernity is usually associated with secularization, the idea of progress, the dominion of facts, the systematization of knowledge in general, and the rise of "science". A strong reliance on science, (arti)facts, and data has been - and still is - a totem of the modern Western approach to the world. There is no doubt that the Brazilian professor fully agrees with Max Weber when he referred to the trajectory of modern thought as the "disenchantment of the world" and thus to its de-theorization. Despite such evidence, Professor Almeida Filho argues that science needs theory in order to be complete. The rise and dominance of new forms of science (biology, medicine, psychiatry, anthropology, psychology, and sociology) have actually led to the preeminence of certain conceptual models for the ways people's health, suffering, pain, and distress are commonly constructed by clinicians, medical experts, and social scientists. In this respect, contemporary biomedical science is responsible for the creation of taxonomies of disease that are assumed universal, value-free, and autonomous from history and culture. All this is clearly stated in Almeida Filho's essay.

Professor Naomar Almeida Filho has also mapped, with an excellent knowledge of current debates, the new territory explored by historians, sociologists, and anthropologists who have argued that both the subjective experience and subsequent recognition, labeling, and interpretation of the health-distress-disease complex are socially and culturally produced (Bibeau, 1995, 1997; Bibeau & Corin, 1994; Foucault, 1966; Good, 1994; Kleinman, 1988; Young, 1995). These researchers advanced the idea that representations, values, and concepts concerning health and disease are inevitably created within a context of multiple forms of knowledge which are as much grounded in local epistemologies as they are linked to the scholarly academic world. These forms of knowledge affect the ways by which the lifeworlds of persons are built and design the architecture of that fuzzy area covered by what social scientists name, with some hesitation, the health-disease-illness-sickness complex. In other words, following Hacking (1995), "styles of reasoning" are integral to both medical discourse and the culturally-framed ideas built around the health-disease complex. Anthropologists have also demonstrated that these "styles of reasoning" vary in important ways across disciplines in academia and according to different social and cultural settings.

Professor Naomar Almeida Filho has investigated, with great scrutiny, heuristic concepts such as "styles of reasoning", "local epistemologies", "systems of signs, meaning, and practices", and "transdisciplinarity", with the intent of formulating the groundwork for a general theory of (public) health. He has courageously navigated on troubled seas, on the ones traveled by medical sociologists and anthropologists who over the past three to four decades have emphasized the socio-cultural dimensions of the health-disease complex, and as well on other seas, even more dangerous, explored by the promoters of critical epistemology in contemporary social, cultural, and medical sciences. However, the time for celebrating the achievements of transdisciplinary collaboration has not yet come, contends Almeida Filho, particularly when one examines the paucity of theories developed around the "substance" of what is health. There is still much fragmentation in the production of knowledge, and theory-building is still a potential proposition, far from being implemented in reality, although biomedical and health-related social scientists have begun to provide new conceptual frameworks for assessing human phenomena, particularly phenomena associated with health and disease.

Professor Almeida Filho has argued that it is through the evaluation of frames, models, and practices commonly used in science (by biomedical and health-related social scientists) that we will eventually gain a better understanding of how suffering, distress, and pain are transformed into nosographic categories and eventually absorbed into the scientific domain. He also notes that it is essential to promote a greater heterogeneity of models, theories, and concepts as a counterweight to the increasing homogenization of disease-oriented knowledge and theory. The perspective that I have explored in my response calls on us all to seriously consider the way ordinary people construct their own models of health and disease. The people I know all live on the boundaries of many worlds and construct their representations of the health-disease complex in reference to a creole grammar. Any theory of health and well-being should take full consideration of this fundamental fact. And I feel that anthropologist Victor Turner (1974:14) was correct when he wrote that "human social groups tend to find their openness to the future in the variety of their metaphors for what may be the good life and in the context of their paradigms". Theories are embedded in responses societies develop to produce "the good life".

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