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 PSYCH  Vol.11 No.1 , January 2020
Notes from the Debate on “Expanded Concept of Health” in Brazil: Ethical-Political Implications and Contextual Mobilization
Abstract: Recent history shows that conceptual issues can undertake potent mobilization in concrete actions of everyday life, as was the case of the debate in Brazil on “expanded concept of health” in the 1980s. It is possible to claim that discussion’s ethical-political aspects had implications for the process that led to the constitution, and implementation of the Sistema único de Saúde—SUS1 in 1990. Based on such assumptions, I develop a theoretical essay aiming to bring part of the rich conceptual discussions on health and disease accumulated in Brazilian Public Health. In the first two topics, I analyze two classic books, “A doença”2 by Berlinguer (1988) and “O que é saúde?”3 by Almeida-Filho (2011), trying to show the differentiated contribution that such works develop with respect to interpretations and contextualization that “health” and “disease” can be offer—in addittion to the biomedical paradigm. Featured categories are addressed in these works, which allow further dialogue with relevant issues of everyday life. Lastly, I argue that the incorporation of conceptual problematizations can bring important contributions related to practices health care, especially in terms of physical education integration’s in the spheres of public health services.

1. Introduction

One of the forms of health is disease. A perfect man, if he existed, would be the most abnormal one could find. Fernando Pessoa, Portuguese poet

The links and disagreements among health, disease, and society (and the meanings of these relationships) have long been deeply debated, revisited, by different areas of knowledge in Brazil and, in particular, by Public Health. From the perspective of the expropriating effects of capitalist production, there are studies that have privileged historical and contemporary approaches to unhealthy living conditions in poor and working classes ( Engels, 1976; Moura, 1989; Breilh, 2010; Dejours, 2015).

Dense criticism has also been formulated regarding the iatrogenic dimension of medicine, to the exclusionary power of large pharmaceutical industry conglomerates, to the social medicalization ( Illich, 1982; Canguilhem, 1991; Sfez, 1994; Conrad, 2007) and to the social and health inequities that condition and determine the collective profile of illness and mortality, predominant in less favored sections of the population4—considering both new and reemerging diseases ( Nogueira, 2010).

These and other classical research works circulating here have been incorporated by Brazilian researchers since the 1970s, forming a consistent tradition of counter-hegemonic analysis by disciplines such as health sociology, medical anthropology, political sciences, health philosophy, etc.

Paradoxically, physical education in Brazil, in my view, is still “weak” in relation to the critical thematizations of the health-disease binomial and its contextual relations. In this sense, important observations are extracted from the arguments of Rigo et al. (2019), when they state that “the conceptual problematic has acquired such relevance that it has compromised most academic debates in the area [...] mainly, by ways in which conceptual divergences are dealt with [...]” (p. 28). The authors follow, pointing to the need to build a more politicized discussion in physical education about “a health perspective [...] that is not biased by the language of dichotomous thinking of health versus diseases, normal versus pathological, life versus death” (p. 48).

In order not to become a meaningless intellectual activity, “conceptualizing” health and disease should not only represent an investment for the understanding of terminologies and their semantic, lexical and etymological correspondences. Rather, it needs to be constituted as a socially situated practice, from which cultural, economic, political, ethical, inherent aspects of the health-disease-care process are recognized, as well as the resulting macro and microstructural repercussions (Breilh, 2010).

And even if certain explanatory notions are adopted to express them (health and disease), it is necessary to recognize that definitions, taxonomies and concepts are limited instruments, employed in an attempt to partially capture the meaning(s) of certain phenomena ... something not always feasible! Thus, however “elaborate” the concept may be, it is only an inaccurate symbolic representation of reality.

By introducing this problematic scenario and aware of the difficulty imposed by the complex task of working with concepts in a limited textual space (in this case, this article), I seek to dialogue—in a schematic and synthetic way—with excerpts of ideas about health and disease to think about its implications.

I start from two classic works that are very expensive for the field of Brazilian Public Health: “A doença” by Berlinguer (1988) and “O que é saúde?” by Almeida-Filho (2011). From these, some analytical categories highlighted in the respective works were taken. Such references fostered some insights for the intended reflection.

2. Contributions by Berlinguer (1988): “A doença”

Even more than 30 years after the publication of the book “A doença” ( Berlinguer, 1988) in Brazil, the conceptual density and relevance of this seminal work remain intact. The analytical issues raised by this author regarding the daily problems tackled by/in the health field remain absolutely current and essential. It is one of those fundamental books to support a solid theoretical substrate and to facilitate the approach with conceptions and facts linked to the dimensions of health and disease and their conditioning aspects, which are known to go beyond the biological sphere of knowledge.

Giovanni Berlinguer’s legacy and influence, both as an entrepreneurial intellectual (he has a vast production of very important works) and as a militant politician of social causes on the European continent and in Brazil, even after his death in 2015, remain remarkable. The innumerable passages of this renowned Italian sanitarist and bioethicist in Brazilian lands, especially in the 1980s— remnant times of military dictatorship—brought unique contributions to the Brazilian Health Reform Movement. Among them we can mention the effective involvement in embryonic debates and actions that led to the constitution and implementation of the Brazilian Unified Health System (SUS) in 1990.

Thorough proof of the recognized value of the book under consideration in our country is illustrated by the initiative of an important institution such as the Brazilian Center for Health Studies (CEBES)5 which recently made it available online, in full, for free download on its website (http://www.docvirt.com/docreader.net/docreader.aspx?bib=CEBESLIVROS&Pasta=A).

In general, the work spells out how arduous the task of conceptualizing “disease” is, especially if we take into account the numerous differences between the existing points of view (many of them carrying opposite values and worldviews) on the subject. Despite its thematic complexity, the book stands out for its fluent writing, easy to understand, inviting reflection.

One issue is central to the work’s argument: Berlinguer ponders that in relation to civilizations called “primitive”, it would be less problematic to think of illness as the absence or suppression of some vital principle. However, in the modern world this is too conflicting, according to him. In this sense, he uses the example of the World Health Organization (WHO) which in 1946 sought to politically legitimize a “comprehensive definition” for health, bringing to public the idea of “complete physical, mental and social well-being”. However, by portraying health in such a way, by extension, he also raised the existence of an implicit link between “mental and social malaise” and “diseases”. In addition, the WHO definition has exponentially and compulsorily expanded the role of the health sector and the potential for medicalization of society6 (that is, the chances increased of turning into any minor signs of ordinary conflict in everyday life and alteration in the relations between the humans, occasion and pretext for medical-pharmacological treatment).

Another approach of the author, in relief, is the questioning presented to the various dictionary, legal and encyclopedic definitions of disease, highlighting the many contextual inaccuracies and the low resolution of life problems that these terminological contributions offer us. From the presentation of this panorama of ideas, Berlinguer questions provocatively: but what would be disease anyway? And he does so with the clear purpose of inciting a reader’s interaction with his work so that new concepts and perceptions may emanate, reconstruct from it.

2.1. Oppressive Face of Life: Disease as Suffering, Diversity and Danger

In three chapters of the book, the author underlines the negative, painful, and oppressive face of disease. It then appears, dimensioned as “suffering”, “diversity” and “danger”. Berlinguer requires us to put ourselves in the role of the sick, to feel/think their ills, and to try to understand how the disease is harshly tackled by the actors who incarnate it.

When categorizing the concept of disease as suffering, he sought in particular to emphasize that the subject of this action (the one who suffers) cannot be blamed or punished for his illness. There would be, so to speak, “a certain overpowering subsumed by healthy people in relation to the sick”, a fact that would lead to the widening of social inequalities and discrimination that affect the sick. Berlinguer argues that in order to change such a situation, it would be imperative for all people to become viable: 1) the right and freedom to be sick without suffering stigmatization; 2) broad access to treatment, with sufficient and adequate care—whenever necessary—regardless of social status, age, gender, ethnicity or religious belief. These are complex assumptions raised by the researcher, given the acute and profound socioeconomic inequalities prevailing in Brazil, although such issues need to be recognized as urgent priorities for the nation and as the political duty of the rulers.

The disease understood as diversity is another suggested interpretative elaboration. Berlinguer admits that the notion of diversity appears in Western history, pejorative and often, as an abnormality, deviation or condition of inferiority (of the sick) in relation to the population average. The author questions this approach and proposes to bring up the themes of the biological norm7 and the social norm8, to check the decontextualized ways of judging the health-disease-care process in certain situations. The Italian sanitarist stated that in hegemonic approaches, with some constancy, only one of the norms for establishing what would be abnormal and pathological comes into play. From an ethical and social justice point of view, diseases should be understood as differences and not as deviant dimensions (generators of prejudice!). As not all diseases are abnormal, it would also be wrong to state the inverse relationship—between health and normality.

In another part of his work, Berlinguer argued that diseases have at all times been considered a threat to humanity, taken as an imminent danger. Some historical facts exemplify such an interpretation. Among them, it is worth mentioning the idea of medical police (an institution that existed in several countries/continents of the world, in different time records) that employed the concept of “social hazard”. Under the pretext of intervening in diseases, it was sought to prescribe/shape attitudes, values and beliefs to/from citizens to control, politically and socially, the lives of human collectivities. In this period, medicine stood out more for its punitive nature and less for its curative nature; doctors’ clinical conduct was more directed to moral judgments (guided by a dominant, “elitist”, exclusionary ideology) and less to tackling the organic affections.

For the researcher, it is necessary to criticize the contemporary remnants of this ideological orientation, opposing as ethical imperative: 1) the public duty of the State to reduce the incidence of diseases; 2) the need to describe as “dangerous” only the diseases and their propagation vectors, not the sick subjects; 3) the urgency of being responsible for “flagship institutions” (especially public ones) that have a contribution to prevent/eradicate certain diseases, but do not.

A good example of this latter issue is the problem of tackling the global AIDS epidemic and the difficulty of “breaking” patents on antiretroviral drugs—a paradoxical situation, given, on the one hand, the large investment of public funds in research to discover and produce drugs that tackle the disease and, on the other, the holding of a significant number of patents of drugs and raw materials, by private sector corporations.

2.2. Disease Positioned as a Signal and Stimulus

The second section of the book mobilizes a different face of illness processes. In it, the Italian intellectual problematizes them from other conceptions and approaches: the disease appears, then, positioned as a “sign” and as a “stimulus”.

Taking the disease as a sign implies accepting its symbolic connotation, which would be translated by the sum and interpretation of pathological episodes: an informative potential related to issues of an economic, cultural, political and social nature, providing clues for understanding more complex phenomena that occur in the different human collectivities (in both retrospective and prospective dimensions). However, Berlinguer warns that these signs are sometimes pointed to by such a veiled, subtle, distorted imbalance, that it is practically impossible to take any remedial or preventive action to the problems, when detected.

In the analysis of the disease as a stimulus, even dealing with events initially circumscribed to the biological and individual sphere and with undesirable effects, it would be possible to establish a broader network of psychosocial, subjective meanings, “around” and “about” the illness process. In this sense, it would make sense to project diseases as complex events that also lead to the acquisition of knowledge, which fosters creativity (to tackle with unexpected situations), which unleashes solidarity (from the sharing of affections to other feelings that emerge from limiting situations of human suffering). While on the one hand, diseases can lead people to isolation, on the other hand, it is equally reasonable to think that they enhance situations of resistance that generate learning of new strategies for living.

These approaches bring renewed perspectives to the health sector. Without daydreaming, it is reasonable and feasible to think of the challenge of reducing, in number and severity, a set of diseases—whether due to the clinical evolution in the tackling pathogens, or to the social consequences in terms of decreasing the percentage of people affected.

3. Cutting of Systematizations of Almeida-Filho (2011) in “O que é saúde?”

One of the central motes in this study is its questioning spirit, which has been highlighted since the title, where the word presented in the form of a question appears: “o que é saúde?”. This type of problematization has been dealt with in the trajectory of the Brazilian epidemiologist since the mid-1980s, revealing his dissatisfaction with the theoretical poverty of the epidemiological field. For him, this is because the concept of health has long been one of the “blind spots” of health sciences, in general and, epidemiology, in particular.

Systematic discussions are developed throughout the work that impose questions of different orders to the concept of health, worked from an etymological, philosophical and scientific perspective. Health is approached by the author: 1) as an individual phenomenon (pathophysiological), almost unanimous conception in biomedical references; 2) as a measure, a category that allows Naomar to investigate the limits and possibilities of the quantitative treatment of health-related events, both individually and econometrically, in terms of their “objectivism” (mote also based on strong criticism by authors such as Canguilhem); 3) as an idea, whose incorporation of personal experience and symbolic aspects is fundamental, because from them the subjects would seek to “manage” pathological processes that generate suffering. However, these three models (“phenomenon”, “measure” and “idea”), according to Almeida-Filho (2011), restrict the health perspective to the absence of disease, when in fact it comprises processes and vectors that largely extrapolate such conventions.

In the chapters that follow in the book, health appears as a problem. In this topic, the Brazilian researcher critically raises emblematic questions such as the conceptual opposition between virtue and vice, an analogy extended from the polarization between health and disease (the latter, taken as ugliness, moral weakness). He uses the arguments of Canguilhem (1991) to state that such conceptions would be absurd, since health is realized in the genotype, in the subject”s life history and in the subject”s relationship with the environment. Hence the reason for the French philosopher to argue that understanding health as a “philosophical problem” does not contradict the idea of also taking it as a “scientific problem”: it would fit both assertions!

Health is also analyzed by Naomar as value in its logical, theoretical and methodological bases. In this sense, he brings contributions from Christopher Boorse, who questions the concept of “health as value” referenced in two counterarguments: 1) on the one hand, remembers that medicine “treats” many conditions it does not define as “health”, such as cosmetic surgery for aesthetic purposes; 2) and on the other, argues that even beyond the reach of biomedical technology, problems of untreated or neglected diseases, terminal conditions of the sick and severe trauma are considered “disease”.

From these paradoxes it is reasonable to admit that the socially perverse gradients reproduced in our collectives, reflect, among other things, interactions among biological differences, social distinctions and inequities in the ethical-moral sphere, always having as their concrete expression unjust health inequalities.

John Rawls is another theorist used by Almeida-Filho (2011), due to his valuable intellectual contribution about the concept of health positioned as a value, which is expressed in what he called “theory of justice”. Rawls emphasized equality of opportunity and also the distribution of values, goods and services as basic requirements, which for him are socially unquestionable needs.

At the end of this topic, Almeida-Filho (2011) indicates the urgency of politically engaging this conceptual and methodological construction in order to enable it to support a mobilization in decision-making structures, in order to press them so that unjust social differences are minimized and so that gender, ethnic-racial and class distinctions cease to stand out as perverse aspects that are striking in determining the illness process and population mortality.

In another category of analysis, “health” is highlighted in the book of Almeida-Filho as a field of practice. Through it, the concepts of “paradigm” and “social field” are introduced. Thus, the Brazilian epidemiologist interprets health as a convergent space of knowledge and social practices. Thomas Kuhn is taken as a reference to conceptually frame the idea of “paradigm”. The thinker proposes two sets of meanings for the term. First, as an epistemological category, “paradigm” would constitute an instrument of abstraction, a kind of auxiliary tool for systematic health thinking. Then “paradigm” would represent a peculiar worldview, usually in the form of metaphors, figures and analogies, typical of the scientific social field. In turn, the concept of “social field” is evoked through the ideas of Pierre Bourdieu. In contemporary pragmatic epistemologies, “field” is defined as a relatively autonomous collective space constituted by a structure in networks of objective relations. Juan Cesar Garcia is another author highlighted by Almeida-Filho, as the first intellectual of health field to use the term “paradigm” in the Latin America. Currently employed to designate different ideologies, the notion has been presented successively in the Brazilian health sphere, historically connected to the Preventive Medicine movements, after Community Health and, more recently, Public Health.

Finally, I highlight in the work the position of the Brazilian researcher, by conceptually proposing health promotion as a “general field of practices” that supposes a social repertoire of preventive actions to morbidity and mortality, but also (and mainly), protective and health-promoting strategies—to some extent try to contribute to reducing the suffering caused by health problems in communities. According to Almeida-Filho (2011), more important than formalizing vigorous methods to measure health inequalities, it would be to understand their roots and determinants; it would be to make concrete efforts to reverse such a socially unfair framework and to enhance—even if in the long term—a collective project involving the happiness and dignity of human life as a tangible reality, which would also make significant contributions from the health sector.

4. Disciplinary Transposition to Conceptual Convergence: Final Notes on the Implication of Debate

Despite the title of the two conceptual works “A doença” ( Berlinguer, 1988) and “O que é saúde?” ( Almeida-Filho, 2011) appear to have a supposed etymological antagonism, besides the significant time that separates their respective publications in Brazil, both enunciate much more convergences and similarities than differences and distances. Giovanni Berlinguer and Naomar de Almeida-Filho offer us two beautiful analytical works, whose ethical-political and academic orientations intertwine mainly due to the similar critical force and complementary affiliation of some theoretical matrixes.

We highlight the significant collaboration that the two books bring to the different areas that make up the public health field in Brazil. Although the Brazilian edition of Berlinguer’s work is over thirty years old, his conceptual approaches remain as current as those of Almeida-Filho. In “A doença”, the Italian researcher suggests multiple adjectives connotable to diseases, as occurs in relation to the word “health”, in the work of the Brazilian author ( Almeida-Filho, 2011).

Another very important epistemological convergence point between productions appears as the authors similarly identify that each term inevitably leads to the other. This is because the meanings are equally implicated in the human vital process: 1) either in the biological sphere or in the socio-cultural dimension; 2) manifested in a concrete or subjective manner; 3) whether collective or individual in nature. From this perspective, there is one more common interface that permeates the two books: they reject thinking of “health” and “disease” as “separate phenomena”, distant from the procedure of life, apart from people’s everyday context.

The authors also share the perception that any “candidate” concept to contemplate “universal truths” is bound to generate more inconsistency and ambiguity than enlightenment and help. Therefore, they propose that we explore the interpretative potentiality that each theory or explanatory dimension about the health-disease-care process can offer us, without failing to admit the failures and limitations of these models, without working to avoid hiding such conflicts and insufficiencies.

In this sense, it is an indispensable task for the academic community to raise mechanisms for the different areas of knowledge to establish a careful and perennial exercise of reflection, in the identification of the judgments that underlie the conceptions of health and disease (as well as their possible political relations and ethical developments) defended by their professionals, since these are the aspects that have determined the priorities in terms of social intervention of the respective fields.

One of the “questions” that still persists in judging health investigative priorities in the Brazilian academic field, in some disciplinary areas that subordinate it to its definitive precepts—including physical education—is the indiscriminate instrumental use of hierarchical and classifying notions, as a way to see (or reduce) the problems that interfere with the conditions of human life.

This becomes even more complicated from the perspective of public policy formulations for tackling health problems, when the concrete aspects of daily life are, in a way, undervalued as guiding criteria of concerns, to the detriment of the exultation of abstract “operative tools” and dangerously homogenizing in character.

Thus, this framework highlights valuative options on the part of the scientific community in Brazil, which have determined a preferential direction for the “operationalization” of these concepts (and for the aggregation of their “utilitarian arsenal”), rather than the exploration of other possible methodological interfaces that better tangent reality. This fact is quite significant. With caution, it must be remembered that science is, above all, one of the most genuine activities and representative activities of human culture, even though its utopian Enlightenment dimension of promising progress extended to the entire population has been lost in its historical discourse.

It has been known for a long time that the theorizing about links and disagreements among health, disease and care—both collectively and individually— in their different interpretative academic strands, depends on the “paradigmatic lenses” from which we choose focus/frame societies, their tensions and conflicts.

By way of illustration, it is worth remember the historical importance occupied by the debate about the “expanded concept of health”9 in the 1980s and its contextual developments that led to the implementation of the Unified Health System (SUS) in Brazil in 1990. This fact suggests the potent mobilization that conceptual issues undertake in concrete actions of life, both in the macrostructural sphere and in the micro-everyday level of relationships.

The promising widening of this prospective horizon depends greatly on widening the boundaries of criticality in the academic and social arenas involved in the debate of such issues. The exercise of politicizing concepts and ideas in spaces of human formation—either in the university or in public health services— certainly strengthens and constitutes a vital part of such a process, especially because it dialogues more deeply with concrete aspects of our existence.

Despite its position as an “emerging” disciplinary field in public health policies in the country for over a decade, Brazilian physical education is generally supported by an incipient tradition and scarce research/graduate degree investments, as to the necessary problematizing reflections about the triad health-disease-care. Such initiatives, if expanded, could perhaps generate unique alternatives in relation to the conservative way of producing, thinking and investigating health practices, still prevalent in the area.

The understanding about the false dichotomy between “health” and “disease”, that there is a factual complementarity between the meanings of the words (which bring them closer than they push them away), and especially about the representative/mediator intertwining that both concepts assume in the care practices in the national scenario, bring scientific, ethical-political and praxiological contributions fundamental to physical education. Above all, in terms of its contemporary insertion in public health services in Brazil, at the primary care level.

NOTES

*The author is responsible for the translation of all official names from Portuguese into English, seeking the best possible equivalents between phrases, expressions and institutional names.

1Unified Health System.

2“The disease” ( Berlinguer, 1988).

3“What is health?” ( Almeida-Filho, 2011).

4The expression “least advantaged groups in society” applies to nations from all corners of the planet, with a greater emphasis on third world underdeveloped countries, including Brazil; not because of its economic strength or the magnitude of the wealth produced here, but because of the asymmetrical, perverse and wicked distribution of all this wealth to the vast majority of the Brazilian population (poor, uneducated and excluded from the opportunity for social advancement).

5Brazilian Public Health Historical Entity (www.cebes.org.br)—copyright holder of Berlinguer’s book.

6In fact, a neuralgic theme deepened by other leading intellectuals in the field ( Illich, 1982; Conrad, 2007).

7In this regard, see Canguilhem (1991) in “The normal and the pathological”.

8Also, on the subject, there is an interesting text by Lewis (1998) entitled “Health as a social concept” which was published in the journal Physis.

9Other contextual developments of this same debate lead to the Brazilian Health Reform Movement; to the VIII National Health Conference held in 1986, and the publication of the National Humanization Policy of Health Practices in 2004, and the National Health Promotion Policy in 2006, among many other important milestones of public health policies in Brazil.

Cite this paper: Bagrichevsky, M. (2020) Notes from the Debate on “Expanded Concept of Health” in Brazil: Ethical-Political Implications and Contextual Mobilization. Psychology, 11, 146-156. doi: 10.4236/psych.2020.111010.
References

[1]   Almeida-Filho, N. (2011). O que é saúde? Rio de Janeiro: Fiocruz.
https://doi.org/10.7476/9788575413432

[2]   Berlinguer, G. (1988). A doença. São Paulo: Cebes/Hucitec.
http://www.docvirt.com/docreader.net/docreader.aspx?bib=CEBESLIVROS&Pasta=A

[3]   Breilh, J. (2010). Epidemiología: Economía política y salud (7th ed.). Quito: Casa Editorial.

[4]   Canguilhem, G. (1991). The Normal and the Pathological. New York: Zone Books.

[5]   Conrad, P. (2007). The Medicalization of Society: On the Transformation of the Human Conditions into Treatable Disorders. Baltimore: The Johns Hopkins University.

[6]   Dejours, C. (2015). A loucura do trabalho (6th ed.). São Paulo: Cortez.

[7]   Engels, F. (1976). La situación de la clase obrera en Inglaterra. Madrid: Akal.

[8]   Illich, I. (1982). Medical Nemesis: The Expropriation of Health. New York: Pantheon.

[9]   Lewis, A. (1998). A saúde como conceito social. Physis, 8, 151-174.
https://doi.org/10.1590/S0103-73311998000100009

[10]   Moura, D. (1989). Saúde não se dá, conquista-se. São Paulo: Hucitec.

[11]   Nogueira, R. P. (Ed.). (2010). Determinação social da saúde e reforma sanitária. Rio de Janeiro: Cebes.

[12]   Rigo, L. C., Pardo, E. R., & Silveira, T. T. (2019). Hable consigo mismo: Aportes de un plan de inmanencia ética, estética y política de los conceptos de salud. In: Bagrichevsky, M. (Ed.), Salud, cuerpo y sociedad (pp. 28-53). Blumenau: Instituto Federal Catarinense.

[13]   Sfez, L. (1994). La sante parfaite: Critique d’une nouvelle utopie. Paris: Seuil.

 
 
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