CARTAS LETTERS

The consecrated Debate Section of Cadernos de Saúde Pública (Reports in Public Health) has been a space for exchange of ideas that has succeeded in awakening readers' interest and providing a forum to discuss key aspects in various areas of specialization. Meanwhile, it has allowed access by other specialists to the wealth of this broad and multifaceted field, in addition to making academic production more alive and heated through debate among peers. It behooves us to identify an apparent difficulty in this exercise. It is not uncommon for disagreement in the intellectual terrain to be interpreted as incompatibility or struggle for prestige at the interpersonal level. I state this proviso in order for the ongoing debate after the rebuttal by Naomar de Almeida Filho (NA-F) to reflect my friendly personal relationship with the author (see Cadernos de Saúde Pública, v. 17, n. 4, pp. 753-799, 2001).

Having said this, I should point out that the way NA-F responds to some of my comments on risk suggests a simplicity of answers that can give rise to a trivial reading (albeit certainly unintentional) of the questions. In order to attempt to clear up this possible misunderstanding, I first need to indicate the excerpt from my comments concerning NA-F's text:

"An example is the mode of health referred to as '1 - risk' (...)" [p. 774, paragraph 5].

NA-F replies: "Luis David Castiel states that the concept of risk is (...)" [pp. 793, paragraph 4] and also "Yet the only frame of reference for the risk concept that I recognize as scientifically based (...)" [paragraph 5].

Very well, it is undeniable that the technical-scientific definitions provided by epidemiology seek to stipulate precisely what risk is. Indeed, stipulative definitions promote a set of equivalent terms and/or operational procedures to establish proper applications of the respective terms and their links to other terminologies. Therefore, such definitions require mathematical formulas, data, quantitative relations, and other precautions for the rigorous application of "risk" in well-specified situations (see W. Dean & P. B. Thompson, 1996 at http://www.fplc.edu.risk/proRisk.htm). Upon mentioning risk as an operational notion in Internal Medicine and as a praxiological notion or "social perception" in common social discourse (by the way, if I understood this notion properly, social discourse is far from being shared in the common sense...), NA-F ends up inadvertently pointing to proteiform, undisciplined aspects of the term "risk". Precisely, I meant to indicate that the concept of "risk", despite efforts to formalize it, is not as stable as NA-F would have it when he defends controversial demarcating criteria as to what is "scientific" so as to allow only for stipulative definitions.

Still, I feel that this topic merits more detailed analysis. My question relates to approaches that go beyond the realist, technical-scientific dimension (in epidemiometric terms) of the construct at hand. D. Lupton (in: Risk Key Ideas, London: Routledge, 1999) proposes an attempt to systematize distinct epistemological approaches to risk from the social sciences perspective. Thus, the author identifies the following positions: (a) Realist. Risk is a danger, an objective threat that exists and that can be measured independently of social and cultural processes, but that can be distorted or biased by social and cultural interpretative frameworks. This position is visibly taken by epidemiology and by the majority of theories from the cognitive sciences that approach risk perceptions; (b) "Weak" constructionist. Risk is a danger, a threat inevitably mediated by social and cultural processes and that can never be known separately from these processes. This position involves perspectives of "risk society"/critical structuralism (Ulrich Beck) and also "cultural/symbolic approaches/functional structuralism (Mary Douglas); (c) "Strong" constructionist. Nothing is a risk per se. What we understand to be a "risk" (or danger, threat) is the product of "ways of viewing" that are historically, socially, and politically contingent, involving perspectives of "governmentality" (Foucaultian authors/post-structuralism).

In addition, to point out that groups are at risk which reach a relative risk (RR) of more than 1 (according to epidemiometric canons) is undebatably correct. But my concerns are not related to this. In practical terms, whether in the dimension of health care, in socio-cultural aspects, or in the world of individual internal/psychological life this general statement may be irrelevant and perhaps even out of place. For example, an eighty-year-old with total and LDL cholesterol levels compatible with a relative risk of 1.5 for cardiovascular diseases may not necessarily need a prescription for lipid-lowering drugs. Furthermore, an individual in this age bracket with cholesterol levels equivalent to RR = 1 for cardiovascular disease is not necessarily dispensed from protective dietary and physical care. An equivalent problem was explored and subsequently debated after an article by Gary Taubes in Science (v. 269, pp. 164-169, 1995). One of the issues raised by the author was what relative risk value a supposed risk factor should present to justify publication of the article in specialized journals!

As is known, mensurationalism can lead to apparent abuses in the utilization of its devices used to construct objects of knowledge. To attempt to review the highly noble contents of the objects resulting from the mode of scientific production as indicated by NA-F's statement, "But as far as I am concerned, objects are precisely the noble product of this peculiar mode of production that constitutes science", an example (prone to raising smiles) refers to a line of meticulous quantitative studies published by a respectable journal concerning the stipulation of chicken soup's potential effects on the common cold. For example: research to evaluate the effects of chicken soup on inhibition of neutrophil chemotaxis (considered responsible for the inflammatory response) in vitro (B. O. Rennard et al., in Chest, v. 118, pp. 1150-1157, 2000), among others. As the popular Brazilian saying goes, prudence, money in the pocket, and chicken soup never hurt anyone... There is now strong evidence for a technical-scientific confirmation that chicken soup can help cure the common cold.

Yet what concerns me the most is the hyperproliferation of these noble objects (especially in the techno-scientific dimension and along with technical benefits) which have led to obvious and dizzying shifts in their capacity to produce meaning in current societies, with striking repercussions leading to great societal perplexity and identity breakdowns. There is an anxiogenic plethora of signs in search of meanings. When such signs occasionally achieve some meaning, they soon vanish and are replaced by more signs in search of new meanings. I believe it is important to focus on what Z. Bauman says (in: Modernidade Líquida, Rio de Janeiro: Jorge Zahar, 2000), speaking in striking fashion of "modernity" on the threshold of the 21st century, as at the beginning of the 20th century: "(...) the most that one can say is that it is modern in a different way. What makes it as modern as it was more or less a century ago is what distinguishes modernity from all other historical forms of human experience: the compulsive and obsessive, continuous, irrepressible and always incomplete modernization (author's italics); the oppressive and uneradicable, insatiable creative destruction (or destructive creativity, as it were: 'to clean the place' in the name of a 'new and improved' project, to 'dismantle', 'cut', 'shift' 'combine', or 'reduce', all this in the name of a greater ability to do the same in the future - in the name of productivity or competitiveness" (p. 36).

A final comment on the version of NA-F's text that I received for the debate (which was subsequently translated into English and reviewed by the author), but still bearing the original title in Portuguese, Modelos de Saúde-Doença: Preliminares para uma Teoria Geral da Doença, NA-F states that the word obverso [obverse] "is recorded in the Aurélio dictionary as a technical term from Botany" (p. 24). Obviously, as NA-F himself says, it would be untenable to disagree that Aurélio "is not exactly a philosophical source worthy of immediate credit" (p. 794). Yet in order to keep my quote from being seen as trivial, it is worthwhile to mention that I saw in my edition of the dictionary something more pertinent to the debate than stating that obverse was "a special shape of leaf". Indeed, I am very pleased to see that my "obsessive care" has been creatively exploited by NA-F in his rebuttal. Besides, without going into the psychodiagnostic merit of the obsessiveness of "all of us proud children of science", I confess that in my specific "psychiatric case", I feel somewhat uncomfortable at being included as such "proud" scientific offspring. I would feel more at home with an adjective like "perplexed" or "ambivalent" (in the sense used by Bauman).

To conclude, I should mention the senseless prospect of proceeding indefinitely with the excitement of this argumentative elaboration. Furthermore, I wish to point out the existence of other aspects in NA-F's rebuttal whose pertinence I admit, even though I could surrebut on other aspects... In such a case, however, I believe the exercise would begin to lose its enriching and entertaining aspects while assuming infertile traits, justifying criticism against the unpleasantly narcissistic side of academicism. Furthermore, it could easily foster an unwanted reading of such intellectual exercise as pointless "mental auto-eroticism". In a word, all potential surrebuttals aside, I wish to close once and for all with great pleasure and express my gratitude for the precious opportunity to contribute in an intentionally obverse/obsessive way to the stimulating debate spawned by NA-F, whose generous and patient attention I acknowledge.