DEBATE DEBATE

Debate on the paper by Nelson Filice de Barros & Everardo Duarte Nunes

Debate sobre o artigo de Nelson Filice de Barros & Everardo Duarte Nunes

Paulo César Alves

Faculdade de Filosofia e Ciências Humanas, Universidade Federal da Bahia, Salvador, Brasil. paulo.c.alves@uol.com.br

Problems with the definition and classification of healthcare systems 

The main objective of the paper by Nelson Barros & Everardo Nunes is to define and classify Complementary and Alternative Medicine. This concern is essential for understanding basic structural aspects in the healthcare system. The discussion is currently being reclaimed by the social sciences, and in a sense it is new to clinical medicine. Still, although there has been an undeniable growth in the specialized literature, the meaning of Complementary and Alternative Medicine is still not completely clear, nor is it a consensus. In this sense, the paper by Barros & Nunes is both timely and welcome, highlighting some essential epistemological questions for resuming this discussion.

In the following brief comments, I wish to focus on just one of the article's central issues: the confusion and imprecision of meanings in Complementary and Alternative Medicine. I believe that the authors are correct when they identify this characteristic in our specialized literature. My fundamental question concerns the reason for this phenomenon. What are the principal factors than can explain the reigning confusion and imprecision in the meaning of Complementary and Alternative Medicine? This question also presupposes another: what is the state of knowledge and the place this "modality" of medicine occupies in the current Brazilian academic scenario? Barros & Nunes do not purport to respond directly to these questions, which however appear pertinent to me; in a sense they underlie the authors' article.

My point of departure is that the question raised tells us something important about the current socio-cultural and theoretical/methodological context of the social sciences. In this sense, the question is also of a "meta-theoretical" order. In short, my question appears to point to the very limits of the social sciences' traditional orientations, since a priori it is more of an epistemological question than something present in the world of social agents' daily lives. Could it be that in our therapeutic itineraries the individuals are concerned precisely with establishing major differences and definitions concerning the arenas that constitute the various sectors of the healthcare system? And there is a troublesome side to the importance of questioning the imprecision and confusion in the meaning of Complementary and Alternative Medicine. Why haven't the social scientists obtained more satisfactory definitions for something that is experienced in such a "non-problematic" way by individuals and social groups? Doesn't this entail an issue that pertains more to backing by scientific knowledge?

I begin my argument by asking about the state of knowledge and place occupied by Complementary and Alternative Medicine in our academic scenario. To what extent does it constitute a new theme for the social sciences? This question involves a provocation, not for the authors, but for the very parameters used in the studies within the health field. In this sense, my comments relate more to the theme developed by Barros & Nunes than the paper itself.

I note that earlier in my comments I used the word "reclaim" to refer to the recent interest in the theme. The term is appropriate, since health anthropology began its studies by focusing predominantly a set of therapeutic practices that the authors referred to as "anti-ethical types". Still, since the 1970s there was an unequivocal reduction in this type of concern, due to some clearly identifiable factors. One was the importance ascribed to the role of intellectuals and their link to the country's broader fate. Circumscribed within an ideology of development, intellectuals were expected to explain the process of reclaiming the national consciousness, taking a critical stance towards manifestations of "folk culture", which was usually viewed as the traditional knowledge of the subordinate classes, alienated from the civilized world. This conceptualization ended up consolidating a structural and ideological dichotomy between the knowledge of the "progressive" elite, committed to building the project for transforming Brazil, and the subordinate classes, representing the country's "backward" and "conservative" cultural forms. I say consolidate, because the social sciences developed from the 1970s to 1980s reproduced (with other parameters) an "elitist" tradition, so striking in our social thought. This fact is particularly interesting in the ideological context of the time. Inspired by Marxist tradition, a major portion of our academics have failed to give due consideration precisely to a premise of this theory: that the proletariat is the only class capable of possibly developing progress in a more coherent way.

Despite some contrary considerations (suffice it to recall the so-called "Paulista School" developed by Roger Bastide and Maria Isaura Pereira de Queiroz, among others), studies on beliefs, rituals, and daily practices (as well as ethnographic reflections) were subsumed in certain research topics that ended up occupying a predominant place in the academic context of the time, such as "development", "national policy", and "Modern Society". More precisely, they were subsumed in the way by which hegemonic theoretical and methodological orientations conducted the analyses of our reality.

Thus, the 1970s and 80s were not exactly favorable to the broad development of cultural reflections, since they tended to limit the field of daily practices and interactive processes merely to their integration into public spaces, government policies, or state issues. This fact is relevant because it shows how the "view" of social sciences reveals certain aspects of reality, while disguising others.

In the sphere of social sciences in health, from the 1970s to the mid-1990s, there was a clear emphasis on the "politicization of medicine" and research into processes of rationalization, institutionalization, and organizations in the official medical systems. Concerned with the macro-interpretations of a historical and structural nature, our researchers were inclined to compartmentalize the constitutive arenas of the healthcare system, subdividing them into sectors with well-defined borders. Furthermore, they only prioritized the cognitive structures and representations existing in each sub-sector. Our social scientists were heavily inclined to identify the "tensions" or "conflicts" between the different "explanatory models" for disease and thus failed to appreciate that in daily actions, individuals who seek treatment "break" with established patterns, assimilating, evaluating, judging, and interconnecting the knowledge and practices from the various arenas. In this sense, the compartmentalization of different treatment sectors should be understood much more as a process of scientific classification than actually as a practice by individuals and social groups.

Such orientations have undeniably enhanced Brazilian social thought and were rich in experiences, but their reason for being has been historically exhausted. Currently, all evidence indicates that the situation points in a different direction. The increase in both qualitative research and utilization of new theoretical references (or at least new for the Brazilian reality) has led our researchers to focus special attention on inter-subjective and discursive processes and observe in them that "social meanings" are never completely predetermined, since they are always linked in specific interactive contexts. In this regard, a theoretical and methodological element that I consider key to the studies on the definition and classification of healthcare systems relates to processes of combination and interaction that actors construct socially when they experience episodes of disease or affliction. Thus, the major challenge in establishing the meaning of Complementary and Alternative Medicine is precisely to make "intelligible" the movement by which individual praxes and social structures self-constitute and mutually reconstitute.