DEBATE DEBATE

Local epistemologies and general theory of health: a rebuttal

The commentary by Roberto Briceño-León shows profound skepticism as to the feasibility or even validity of a proposal to conceptually develop the health object in the direction of a General Theory of Health (One of the other commentaries defends a position similar to that of Briceño-León but includes a set of non-systematic and impressionistic propositions on the health theme, without even referring to the content of the essay under debate. In said commentary, the use of concepts is quite idiosyncratic and disconnected from the theoretical schemata I have analyzed, thus hindering its incorporation into the present line of debate. I thus lack a basis for incorporating it into this rebuttal).

Before analyzing the content of Briceño-León's critique, I should point out some misunderstandings I find in this commentary: in my article, I did not appeal to the concept of sickness to define health, did not propose any definition of health, and did not state that health was something that is lost. Briceño-León purportedly agrees with Gadamer (1996) by taking health as a feeling, a living experience, an effect of subjectivity, an element of individual imagination. He contends that sickness constitutes a social construct, while health would be a construct "located in the shifting terrain of desire". I cannot agree with such a position. In preparing for this debate, I ended up overcoming that hint of doubt by reviewing and reaffirming the main argument in my text. In full agreement with Samaja (2000), I refer to the indication of plural, multifaceted, and multi-leveled nature of health, which can manifest itself in different hierarchical planes of complexity. Thus, Gadamer's proposition (and Briceño-León's "intellectual free ride") would only apply to the individual level, where unique, private, subjective - in a word, individual - space is realized.

I must also contest Briceño-León's verdict that "Health as a general theory does not exist [because] there are only historical claims". Two assertions result: first, that health is not justified as an object of science; second, that theories are not historical constructs. The epistemological principles that sustain this line of argument are incompatible with the dominant approaches in contemporary theory of knowledge. It is not the attributes of events or phenomena that determine the construction of the object-model but scientific praxis marked by the limits and barriers (conditioning factors) of concrete reality (Samaja, 1994). The theories, in turn, are essential tools in the process of constructing the object, always beginning as "historical claims" (or knowledge projects) and becoming both historical and formal constructs.

Luiz David Castiel states that the concept of risk is "conceptually frisky [undisciplined - T. N.]", in the sense of displaying a certain mutant and imprecise nature. In epistemological terms, I do not agree. There are few objects of science with such a rigorous degree of formal elaboration as the object-model "risk" in the field of Epidemiology (Miettinen, 1985). As I had the opportunity to point out in A Clínica e a Epidemiologia (Almeida Filho, 1992), the term "risk" appears in epidemiological science (and also in Economics) as a theoretical concept, in Clinical Medicine as an operational notion, and in common social discourse as a praxeological notion or as "social perception". Castiel insists and asks: What cut-off point clearly defines which groups are actually at risk and which are not? How does one deal with the more vulnerable groups (by age, gender, ethnicity, etc.)? The answer to the first question is simple, at least in epidemiological terms: the threshold for ascribing the risk factor category is a relative risk of 1.0. For the second question, suffice it to apply the notion of "reference classes" (Boorse, 1977), evaluating normal functions not in relation to what is typical (or exceptional) for the species but for what is typical for the class origin of the subject or group at issue.

Responding directly to other pertinent questions by Castiel, I pointed out in the text cited above that the signifier most closely linked to the popular notion of risk is actually that of "danger". Giddens (1990) and Beck (1996), representatives of an important line of post-Marxist thought, propose that societies developed in a certain direction converge towards a "society of risk". I thus deem worthy of debate Castiel's proposition of employing the SmpH descriptor for risk also and not only for illness. Yet the only frame of reference for the risk concept that I recognize as scientifically based is still Epidemiology. Respecting the possibility and validity of approaching risk as a theme in the fields of sociology and anthropology, I prefer to restrict the range of application of concepts analyzed herein based on the position that precisely there lies its efficacy as a heuristic device.

I thank Castiel for enriching the current debate, commenting in depth on the topic of prototypes, clarifying its origin and conceptual insertion. However, I disagree on several points in this regard. Indeed, Lakoff (1993) does grant all the credit to Rosch and his school, but advances considerably in the formal consistency of the concept and its generalization to other themes beyond biology and the psychology of perception. Rosch's theory of prototypes cannot be "amenable to immediate understanding" by fuzzy logic, but Lakoff's theory of prototypes certainly will be, since the author himself so indicates based on an analysis of the insufficiency of classical logic vis-à-vis the conceptual requirements of ambiguous and imprecise objects. Castiel is right in pointing out that originally the theory of fuzzy systems did not mean any break with formal logic but rather an attempt at updating it in terms of categories of gradation. However, its subsequent development outside the technological field (in the narrow sense), principally in the application to analysis of cultural systems as proposed by Lakoff (1993), resulted in an effective alternative to classical logic and the theory of discrete sets derived from it.

In the field of health, there are practically no applications of the notion of prototypes, despite its undeniable proximity to the problem of superimposed diagnoses or co-morbidity, as highlighted by Mezzich & Almeida Filho (1994), and to the issue of the fuzzy nature of definition for both exposure and risk in the epidemiological frame of reference (Costa-Capra, 1995). An interesting recent update on the subject was published by Sadegh-Zadeh (2000), emphasizing precisely the theoretical and practical uses of fuzzy logic in research on health-disease.

Castiel, careful as he is (or obsessive, like all us proud children of science), should investigate the meaning of "obverse" to determine whether it is actually fitting to use such a category in the health object. First, I should say that it is a proposition by Parsons himself (1978), to whom the fair criticism should be addressed. But since it is no longer fashionable to criticize Parsons for being Parsonian, I contend that it is a subtle and intelligent indication of the dialectic nature of the health-disease dyad. The Brazilian standard dictionary Aurélio is not exactly a philosophical source worthy of immediate credit; in addition, the reference to Parsons is clearly metaphorical. Even so, the sophistic application of the formula "All S is P, by obversion, will be no S is non-P" by my dear critic is correct, and contrary to what he believes to have demonstrated, it contributes to the notion that health possesses a nature distinct from and irreducible to sickness.

Let us consider, following Castiel's line of argument, that P = non(D), or absence of disease. Indeed, if (S) = (P), it follows that

(S) = non(D),

by obversion,

non(S) = non[non(D)]

which, by reducing the negation of the negation, is equal to

non(S) = (D),

thus

(S) (D)

It is thus valid to say, on the logical plane, that it is in fact a relationship of obversion, far from revealing its "fragility and impropriety". But after all, Castiel is free even to prescribe brief and gentle "puzzled pauses [to regulate our] irrepressible drive to know and produce objects". But as far as I am concerned, objects are precisely the noble product of this peculiar mode of production that constitutes science.

Cecília Minayo observes that "to date, health has never been treated as either a discipline or school of thought" but rather as a field of knowledge and practices, in the sense proposed by Bourdieu (1983). She thus considers it "quite problematic to formulate a theory of health or health models" even though it may be possible "to theorize the health concept". In fact, my text was really not intended to enunciate but to announce a theory, covering some essential preliminary stages for the conceptual construction process. The first stage consisted of a duly justified proposition of the positivity of a given concept. I do not know if the text succeeded in meeting this prerequisite, but my explicit intent was to demonstrate the insufficiency of theoretical treatments of the health issue based on the notion of sickness or disease. The second stage aimed to refine the concept, making it more operational as a tool for systematizing thought on a complex object of knowledge. With regard to the present effort, I basically attempted to present and validate the following proposition: similar to the semantic variety of the disease-illness-sickness complex, we should construct an equivalent conceptual plurality, identifying various modes of health.

Minayo also suggests that I fell into a "theoretical trap" by identifying only the socio-anthropological and epistemological dimensions as structuring the health concept, leaving aside the biological dimension. In addition, she questions the very inclusion of the epistemological dimension at the same analytical level of the social sciences in health. Concerning the omission of the biological dimension, I believe that Minayo is right, but cross-sectional approaches impose necessary limits on analytical ambitions. In this sense, the most I can do is to promise to analyze the biological dimension subsequently, in light of the advances and debate produced by the text at hand. As to the question of whether the epistemological dimension is structuring or is part of the meta-analysis of theories, I would simply respond that this disjunction does not make sense. Epistemology may be structuring in an early stage of conceptual construction, resuming its meta-theoretical or para-theoretical mandate as soon as the process of consolidating the object or field advances.

In the purposive part of her commentary, Minayo contributes with a proposal for differentiating health as a total social fact and as a concept handled by a specific field of practices and policies. She briefly analyzes the notion of health as a good, as a conquest, and as social expression, with references to Marcel Mauss's theory of the gift, as retrieved by French structuralism. She then launches into the confusion of logical types characterizing WHO's elaboration on the topic, quoting Oliver Sacks, who paraphrases Canguilhem, who studies Leriche, finally accepting a definition of health-disease anchored at the individual level. The proposal of various "healths", my modest contribution to the inauguration of this debate, unfortunately appears not to have been clear and thus requires ratification. According to my proposition, what Minayo calls health as a total social fact constitutes just one of the modes of health, provisionally designated as "social health" and which has its principal descriptor in the systems of signs, meanings, and practices. It is only as a localized indication that I believe health is theoretically less important as a "social fact" than as a "total fact".

Dina Czeresnia admits that "no scientific definition of health has been found to date," and that the link between the field of health and medicine makes it depend on a negativity to define its object. She thus agrees that it is important to attempt to move forward towards a theory of health destined to support risk prevention and health promotion practices (Czeresnia, 1999). Nevertheless, she suggests that it might be helpful to retrieve the ontological concept of sickness, reconsidering "the form in which this concept is organized in practices that either favor or jeopardize life", which could function as a "margin and barrier" in the process of constituting the object of health (practice). She asks, "Without the inexorability of pain and suffering would a field of health make sense?" And she ends by identifying a possible contradiction between my transdisciplinary proposal/stance, organized as a problem or issue and not as a discipline, and the objective of constructing a General Theory of Health.

I agree that it would really not be possible to go too far in the proposed theoretical undertaking without decisively confronting the theoretical issue of sickness. It is not only the health concept that has been neglected. As I analyzed in my article, despite some well-meaning efforts, not enough progress has been made either for a satisfactory composition worthy of the name "general theory of sickness". However, I am convinced that it is an articulated project, but parallel to progress in the reflection on the concept of health, with distinct objectives and strategies. As for the second question, I see no contradiction between formulating a general (and not unified) theory of health and valuing alternative and plural modes of understanding the object. A general theory like the General Theory of Systems or the General Theory of Information will certainly have a sufficiently broad scope to incorporate restricted theories of health (or middle range theories, as suggested by Madel Luz) applied to each realm, plane of emergence, or facet in the health object-model.

In the reference to a general theory, as clearly understood by Suely Deslandes in her commentary, the health object may be in keeping with the articulations or interconnections between restricted theories as well as the effects of the horizontal invariance in the health models considered. In other words, "as many theories as there [are] alternative and plural modes of approaching this object" mentioned by Czeresnia doubtless need a meta-structure capable of integrating (and not unifying or merely homogenizing) the various object-models comprising the "single plurality" of health.

Taking another angle, Suely Deslandes picks up on the theme of the choice of functionalist authors as the target of criticism for the negative vision of health and demands that the analysis include "sociologists incorporated into the Collective Health debate (like Habermas, Bourdieu, and Giddens)". Perhaps some important reference has escaped me, but as far as I know none of these authors has dealt directly with the issue of health or sickness. I am unaware of any theory of health in the Frankfurt school, in French post-structuralism, or in British post-Marxism. In the other watershed, as I analyzed in the text at hand, North American structural-functionalism chose the role of the sick individual as central to the social system theory, and interpretive medical anthropology proposed a partial theory of disease-illness-sickness.

Minayo also contends that my text "fails to escape this theoretical entanglement" (another way of indicating the purported theoretical trap) of Anglo-Saxon reductionist functionalism, claiming that the references on which I base my analysis forced a superficial and poorly systematized discussion of the theory of health. First, all the sociological and anthropological references were used in the article as the target of criticism and not for theoretical support. Second, the preliminary movement towards a theory of health could only conclude, and not precede, a guided process of conceptual deconstruction/construction.

Rita Barata also underscores this issue, but referring to other authors of a Marxist reference (Sigerist, Pollack, Garcia) who - and here I do indeed agree - produced theoretical contributions on health that could enrich the debate. Even so, and she herself agrees, none of them analyzed (or even intended to solve) the specific problem of a positive health concept or the absence-of-disease issue. The contribution by all these authors, defined by their critical stance towards the functionalist frame of reference, could not be useful for the project at hand simply because they do not serve as a target or contrast for the conceptual deconstruction I attempted to perform.

Barata further questions whether the analytical scheme developed by Bibeau & Corin, despite being the only "truly social formulation among those analyzed by the author, recovering the historical, social, and collective dimensions of the health-disease process" is sufficient "to consider it an adequate descriptor for the category of social health proposed by the author". This is apparently a fair and timely critique, to the extent that the choice in fact implies an early closing of the proposed frame of reference. However, I should point out that all the indications in this conceptual trajectory are provisional, and this particular one even more so, given that it does not fit among the basic concepts of health disciplines, like risk, morbidity, measure, etc. As I observe later in the text, the reshaping of the SmpH theory by one of its authors in the face of critiques aimed at it in the context of the present debate indicates that this choice retains its heuristic value vis-à-vis the theme of "social health".

Madel Luz provides an in-depth discussion of many of the points raised by the text at hand. She ascribes the theoretical vacuum in the health concept to "the predominance of the biomedical frame of reference in the social sciences", in culture, and in basic societal relations. I confess that it remained beyond the scope of my analysis to investigate the determinants of this conceptual blind spot in the social history of Western science, as Luz herself did (1989) in a pertinent and competent way. Referring to Foucault, she points to the institutional order of the biomedical and social disciplinary fields as a "set of identifications which 'expels' from its theoretical nucleus such positivities as health, life, or vitality". However, she recognizes that a positive conceptualization of health involves the epistemological and institutional deconstruction of the "medical order".

I am happy with the degree of understanding of my text's objectives as displayed by Luz, a partner in lengthy debates on the Collective Health object-model. As I said above, I am modestly happy with the claim to an epistemological deconstruction of an incipient conceptual order (the field of Collective Health), but I would not dare to expand the scope of the proposed critical interference to include an institutional order subject to such deeply established determinations. I agree both with her warnings concerning the danger of unified theories which historically take biomedicine as the basis for unification (note that my proposal is precisely the contrary) as well as with her recommendation to seek a general theory as a finishing line and not as a point of departure.

Jurandir Freire Costa raises the question of cognitive models and the necessary levels of abstraction to foster reflection on a GTH when he recommends "renouncing the intention to construct a meta-theory of health in favor of prompt descriptions, subject to revision and further in-depth development". As a collaboration to simplify research protocols, he proposes to divide the health field into two sets: that of physicalist descriptions - facts postulated as causally independent of meaning and that of mentalist descriptions - all of the mentally phenomenic "qualitative" aspects of the health experience. He ends by suggesting practical modes of implementing this strategy for the theoretical construction of the health object, referring to the difficulties in ensuring compatibility among disciplines and the levels of social validation needed for such a proposal.

Such suggestions provide valuable contributions to the project, but I would like to discuss some specific points. First, to consolidate a meta-theory or general theory is not incompatible with developing restricted theories based on specific developments. As I have already discussed in responding to Deslandes and Minayo, and in total agreement with Luz, I believe it is desirable to conduct a parallel development of the general theory and the restricted theories of health-disease in order to mutually feed the processes of systematizing the cognitive models (or object-models, in Bungean terminology).

Second, as for the phenomenic sets proposed by Freire Costa, I believe that it is another issue of the level or plane of emergence, in which one should also consider mixed descriptions (physicalist and mentalist, parallel or convergent - hence the risk concept is certainly the best example). Finally, I agree with the limited feasibility of obliging "specialists" to command distinct areas of knowledge, given that encyclopedism as a project has long since vanished. However, as I indicated in another series of articles (Almeida Filho, 1997, 1998, 2000), a pragmatic proposal for transdisciplinarity can deal with the necessary synthesis of health as an object-model, single and plural, by means of a new encyclopedism based on the circulation of subjects and not the transfer of disciplinary discourses. In my opinion the conclusion to the commentary by Freire Costa is perfect: we must respect the language of the paradigms without confusing incommensurability with untranslatability.

Jaime Breilh considers the discussion of a General Theory of Health timely, precisely at this moment in which what are called "general scientific frameworks" are being questioned. I thank him for his series of positive comments on my proposition and move on immediately to deal with the critical points he identified. First, Breilh criticizes the excessive dependency on the text's line of argument in relation to European thought and its successors. He is right on this point. Of course the important contribution by the Argentine philosopher Juan Samaja alone could not counterbalance the conceptual construction on the theme of sickness performed by the social sciences applied to health in the Anglo-Saxon context or the French epistemological tradition. The work of Breilh himself (1990, 1995), and that of Pedro Luiz Castellanos (1997), Luiz David Castiel (1994), José Ricardo Ayres (1997), Dina Czeresnia (1999), and many others have certainly contributed greatly to the robustness of the argument. What I can say is that I consider them a "theoretical reserve" for subsequent stages in the conceptual construction process that awaits us.

Second, Breilh introduces a subtle critique towards the academicism and elitism of my arguments, highlighting that the construction of a scientific discourse on health is too serious a matter to be left exclusively to scientists. He contends that a General Theory of Health "should encompass the historical subjects mobilized around the object as a field of action", but he does not identify such a possibility in my proposition. He recommends that the necessary theoretical construction be conducted based on the dissolution of separations between "subject", "objective world", and "mass" imposed by positivist rationalism. In short, he proposes to radically politicize any attempt at developing theories of health, whether general or restricted, employing a reference from multiculturalism that shifts from the original anthropological extraction to a voluntarist militant version.

In this regard, Breilh and I harbor a radical disagreement: while he believes that the persons who are the object of research are subjects fully capable of directly grasping the process of producing knowledge on their own lives, contexts, and systems of thought, I contend that research is a professional practice exercised by those who undergo structured processes of theoretical and methodological training. The concrete subjects constitute subjects of their own lives and health, I agree, but the agents who produce research are subjects of a peculiar institutional and ideological order which, whether we like it or not, achieves relative social and political autonomy in Western social formations. As acknowledged by Bibeau (see below), the notion of social health and the reference to SmpH implies a conscious and feasible opening towards social discourses on health and its correlates, mediated by research praxis.

Gilles Bibeau, one of the authors of the theory of "systems of signs, meanings, and practices in health", recognizes that few anthropologists have taken interest in developing an anthropology of health as opposed to the perspective of disease prevailing in this field. By positioning himself vis-à-vis the nature of popular semeiologies as the basis of belief systems and the role of science as a social and historical response to human demands (including demands for health), he takes a stance that surmounts the romantic ethnoscience movement in vogue in the 1960s. He uses these foundations to "enthusiastically" support both the General Theory of Health project and the deconstructionist and integralizing strategy pursued in the text at hand. He presents a robust line of argument supporting what he considers convergence in our reflection: the search for positivity in the concept, anchored in the discourse of science, in parallel with the introduction of what he calls "local epistemologies" in the construction of a General Theory of Health.

Bibeau effectively "buys" the ideas of conceptual plurality and transdisciplinarity, aligning strategic themes to support the proposal under debate. He begins by discussing the "quest for perfect health" and the "well-being complex" as structuring symbolic sets in the dominant ideology in post-industrial capitalist countries, in which notions like promotion and prevention provide the basis for technological undertakings in social intervention. Next, he approaches the contemporary trend to consider the historicity and relativity of biology, suggesting that perspectives be opened for a new and solid integration between socio-cultural and biodynamic health paradigms. He enriches the line of argument proposed in my text by introducing the linguistic issue as the basis for symbolic and phenomenological analysis of the health-disease complex and its effects and correlations. He then reaffirms the position of considering interconnections between collective systems of meaning, local health idioms, and individual discourses of well-being as essential to articulate a theoretical model of health which in fact respects the complexity of the corresponding phenomenic processes. Evaluating this section of his commentary, I note with great satisfaction that Bibeau intends to move forward with the theory of "systems of signs, meanings, and practices in health", absorbing and incorporating the critique that this theory remained committed to illness models.

In the second part of his commentary, Bibeau aims to contribute to the strategic part of the process of theoretical construction, emphasizing the value of "local epistemologies" for integralizing the health object. He initially justifies this perspective based on the notion of cultural complexity (Hannerz, 1993), pointing out its dialectic nature as a concept based on contradictory pairs like local-global, center-periphery, inclusion-exclusion, and majority-minority. As both a challenge and a promising way out, he comprehends the processes of "creolization" of societies and their cultural systems. He then takes advantage of the opportunity of this debate to indicate that, given that science also constitutes an ideological and institutional network that is part of the modern West's cultural system, it is licit to consider the possibility of a "creolized science".

In the case of the health sciences and their hybrid, plural, and imprecise objects, Bibeau unveils the important role of local epistemologies, which found "popular diseases" and "semantic health networks" on the basis of "implicit health theories". The exploration of such elements by means of competent ethnographic approaches, conscious of their limits as "local knowledge" (Geertz, 2000), constitutes a requisite for grasping the "systems of signs, meanings, and practices in health" which, with greater propriety after this, is justified as a descriptor of "social health" or "health imaginary". In this sense, Bibeau concludes with a quote by North American researcher Victor Turner, who launched an important line of anthropological investigation of suffering, highlighting an expression which in my view will constitute a basic notion for future ethnografies of "social health", becoming a key concept for any creole grammar of the health-disease complex: "the good life". But this is the subject for a new debate...

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