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Revista Brasileira de Ciências Sociais

versão impressa ISSN 0102-6909

Rev. bras. ciênc. soc. vol.5 no.se São Paulo  2010

 

Body and Illness across diferent áreas of knowledge1

 

Corpo e doença no trânsito de saberes

 

Corps et maladie au transit des savoirs

 

 

Cynthia Sarti

Translated by Plínio Dentzien
Translation from Rev. bras. Ci. Soc., vol.25 no.74, São Paulo, Oct. 2010.

 

 


ABSTRACT

This essay discusses the anthropological studies on body and illness from the perspective of the way in which they relate to biological knowledge in the scientific field of health.  Anthropological research implies an attitude before this area of knowledge to the point that the way in which one relates to the other becomes an epistemological problem, defining the status of anthropological knowledge in that field marked by the hegemony of bio-medical sciences.  From this point of view, we distinguish two perspectives: medical anthropology, subsumed under the logic of bio-medical knowledge, and the anthropology of health, whose approach through the notion of culture gives rise to another epistemological reference, pointing to the anthropological contribution to this field that presupposes, in itself, the distance from the references that support bio-medicine.

Keywords: body; health and illness; anthropology of health; bio-medicine; otherness.


RESUMO

Este ensaio discute os estudos antropológicos sobre corpo e doença, a partir da forma como se relacionam com os saberes biológicos no campo científico da Saúde. A pesquisa antropológica implica uma atitude ante esses saberes de tal ordem que a forma como ela se situa em relação a eles se converte em problema epistemológico, definindo o estatuto do saber antropológico nesse campo marcado pela hegemonia das ciências biomédicas. Sob esse prisma, diferenciam-se duas vertentes: a antropologia médica, subsumida na lógica do saber biomédico, e a antropologia da saúde, cuja forma de operar a noção de cultura configura outra referência epistemológica, apontando para a efetiva contribuição da antropologia para esse campo, que supõe, em si, o distanciamento das referências de sentido que sustentam a biomedicina.

Palavras-chave: Corpo; Saúde e doença; Antropologia da saúde; Biomedicina.


RESUMÉS

Cet essai discute les études anthropologiques sur le corps et la maladie à partir de la façon dont elles se lient aux savoirs biologiques dans le domaine scientifique de la Santé. La recherche anthropologique implique une attitude telle faceà ces savoirs que la façon dont elle se situe par rapport à eux se convertit en un problème épistémologique, qui définit le statut du savoir anthropologique dans ce domaine marqué par l'hégémonie des sciences biomédicales. Sous ce point de vue, deux courants s'opposent : l'anthropologie médicale, qui s'insère dans la logique du savoir biomédical, et l'anthropologie de la santé, dont la façon d'opérer la notion de culture configure une autre référence épistémologique, qui indique vers la contribution effective de l'anthropologie à ce domaine qui suppose, en soi, l'éloignement des références de sens qui soutiennent la biomédecine.

Mots-clés: Corps; Santé et maladie; Anthropologie de la santé; Biomédecine.


 

 

The problem

Body and illness are objects whose knowledge has not a sole access.  Social and cultural phenomena - as any human phenomenon - body and illness, as well as pain and suffering, are research objects that cross over disciplinary frontiers, for they involve dimensions of human existence claimed, each of them, as belonging to specific areas of knowledge, corresponding to the disciplinary fragmentation of the scientific field, in this case, between social and biological sciences.  In their study, the problem of the relationship between these different fields of knowledge is inevitably posed; their view-points transform body and illness in radically different objects, for they are constructed from distinct epistemological references, such as those that separate the field of biology - founded on the assumption of the objectivity of empirical knowledge - and the symbolic field of anthropology.  The problem is most clearly seen in the fact that these studies, even from the perspective of the social sciences, evolve in the institutional spaces connected to the area of health, whose organization follows the logic of biological knowledge.  

In a  fragile period in the institutionalization of the social sciences in the area of health, Carrara (1994) emphasized that the discussion he raised, at that time, on the access of social anthropology to the domain of bio-medicine, making it an 'object' of our own 'science' (p. 37), perhaps was of interest only to those, as himself, situated in institutional spaces connected to health, therefore 'hybrid' from the point of view of the traditional division of scientific disciplines. Today, considering the visible institutional expansion of that field of study,2 together with the opening of the social sciences to other areas (law, human rights, public security, international relations, communications, environment, etc), I think the discussion on the terms of the possible communication between different fields of knowledge appears as a problem not only of  general interest for the social sciences, but also necessary to their endeavor.

This essay aims at the discussion of the field of anthropological studies on body and illness, cutting it from the requirement, intrinsic to this field, of defining a  relative situation towards biological knowledge.  It underlines the specific way anthropology itself deals with the questions of body and illness, classical in its studies, mapping it through the way in which anthropological knowledge relates to bio-medical knowledge in that presumably interdisciplinary field.

The notion of "interdisciplinarity" implies a dialogue between disciplines, whose possibility depends on keeping well defined disciplinary differences, making clear  the place from which one speaks and the frontiers that separate and approximate different areas of knowledge, in the tension which inheres to them, for the attempt to dialogue implies some tension in the search for fairness in the postulates of a field before the other.  It is not the case, therefore, of thinking interdisciplinarity from the possibility of identification, but, on the contrary, the possible encounter presupposes a previous separation, implicit in the acknowledgement of otherness.  Identification nullifies the other instead of acknowledging it.  The first step toward dialogue is that of separation, in order for the next step to lead to a possible encounter, if any, between one and the other (Sarti, 2003).

Even though there is a wide recognition, in the area of health, of the irreducibility of human phenomena to the biological dimension, when an anthropologist takes the body, pain, suffering, health or illness as his/her object, he/she will face a field of knowledge where biological sciences are the social reference.  It is a difficult field, marked by power relations deriving from the institutionalized social place of bio-medical knowledge in our society.   This knowledge is the official representation of the human body in the contemporary western world, not only in the realm of the "scientific field" - a field of struggles and disputes, both in its inner mechanics and its relation to society, as shown by Bourdieu (1976) - but also as a cultural reference for society as a whole.

Recurring to Althusser's classical formulation (1985), according to which the mark of ideology is the interpellation of the subject, medicine, as an ideological apparatus, interpellates us permanently, wherever we may be.  It is omnipresent, telling us not only how to cure our illnesses or mitigate our sufferings, but, actually, how to live.  Although it is not the only one and it operates within a field of tensions and ambiguities, bio-medicine dominates over the conception of life and death in contemporary western society.

It is worth noting that "bio-medicine" is here understood as the field of biological knowledge on which medicine is founded, involving the institutions and practices to which it is associated.3   The use of the term coincides with Canguilhem's formulations, according to which medicine is a technique and an art, "located at the confluence of many sciences, rather than a science proper" (2006, p. 6).  This author searches for a relation between (biological) sciences and techniques, unveiling the mechanisms through which scientific postulates (particularly physiological) constitute normative discourses, that impose a standard of normality, a sole reference to think illness (and, consequently, treat it), seen as a quantitative variation (therefore, to be measured) of the "normal" state of health.  His argument in favor of a qualitative difference between health and illness - for the pathological state corresponds to a "negative value" relative to "life" - shows the historical character of what constitutes (and institutes) itself as scientific conceptions of  normal and pathological. Thus, it allows for the relativization of such concepts, giving way to what clinical experience and the ill persons' discourse - and not only "science" -have to say about illness.  So, from the point of view of a science that informs the clinic, according to Canguilhem:

It is very important not to mix illness with sin or the devil.  But just because evil is not a being we should not conclude that it is a meaningless concept, or that negative values do not exist, even among vital values; we cannot conclude that, at bottom, a pathological state is not any more than the normal state (2006, p. 68).

[...] scientific knowledge, although it invalidates qualities it shows as illusions, does not nullify them.  Quantity is quality denied, but not quality suppressed (Idem, p. 73).

For the anthropologist, defining him/herself within this field of knowledge, facing many kinds of knowledge, is not a new experience, for it responds to the procedure, intrinsic to the discipline, of questioning the terms which preside the relations between researcher and researched. We always ask about the status of our knowledge in face of our research object.

Since anthropology constituted itself as a scientific discipline that studies human societies different from that to which the anthropologist belongs, that is, it studies the non-western world, the discussion of the conditions under which the relation between the anthropologist and the culture he/she studies occurs is  an ethical, methodological and epistemological problem.  Anthropological knowledge is constructed precisely within that problem.  In order to validate itself, anthropology takes into account the dialogue between the scientist and his/her peers, and valid anthropological propositions are also based in the possibility of the dialogue of the researcher and his/her object, as  emphasized by Rouanet (1990) in a paper on ethics and anthropology.

When dealing with the study of  body, health and illness, the object of research becomes, either directly or indirectly, the scientific field itself that produces truth about what are body, health and illness in the western world, that is, bio-medicine and its agents.

Thus, if questioning the place from which the anthropologist sees, hears, speaks and writes is one of the important questions for anthropology (a question in which Geertz (1989) is a reference) or, still, what Clifford (1983) calls "ethnographic authority", that question is posed anew when anthropology takes on the body, health and illness as its objects, assuming a new figure.

The notion of ethnographic authority presupposes that the anthropologist is the authority of knowledge, facing an object whose knowledge socially lacks authority and legitimacy; an authority that was constructed as it is before the non-western world from the rise of anthropology as a part of the human sciences by the end of the nineteenth century and beginning of the twentieth, in the historical context of European colonialism.  The questioning of such authority today, in the context of post-colonialism, derives from the association of anthropological discourse with power, a heritage of the context of the European world that marked the discipline's foundation, defining the supremacy of western knowledge over other forms of knowledge. However, a significant controversy and imprecision emerged from that postulate that is acknowledged as evidently valid to explain the birth of the discipline, but does not serve to understand its own critical development.

The ethical and epistemological question that defies the anthropologist, in what respects the status of anthropological knowledge, is to search for a possible place to the acknowledgement and legitimacy of the discourse of its "object" (that has become a subject), to which it is attributed a status of knowledge, conceiving discourse as a structure that accounts  for the meaning of the enunciated word  as  the practices and relations under which it is enunciated are taken into account.  This question is particularly relevant in the area of health, for the ill person's discourse is not acknowledged by the bio-medical discourse.  However,  acknowledging the other as a subject and recognizing the legitimacy of his/her discourse, is not the same as the (naïf) claim of a presumed symmetry in knowledge, a problem that transcends the place of the research encounter of anthropologist and native in research, and it is a problem precisely because of the terms in which this encounter happened and happens historically.  In this respect, I refer to Duarte's argument:

Today the interpretative disposition if often denounced as an index of the authoritarian privilege of the observer over native experience.  The position of the anthropological project cannot be non symmetric, for the cultural dispositions from which it derives are different from those that inspire and have inspired the life of all other symbolical orders emerging in the world.  Acknowledging that "situational" lack of symmetry does not mean, however, necessarily assuming some ontological or epistemological preeminence over the "natives" (including those of our own societies, popular or erudite, subordinate or dominant, marginal or hegemonic).  The idea that it may be possible, on the other hand, to give the other's conceptions a place of superior truth, - with larger cosmological coherence or existential authenticity, for example - ends up expressing a sophisticate and consummate arrogance, as if the revelation and approval of such ontological dignity depended on us, still its observers (2008, p. 22).           

In what refers to the relationship to the group researched, the anthropologist of health is in a singular situation.  Contrary to what generally happens with his/her peers, he/she has to face the fact that the place of authority, in the interdisciplinary area of health, is not that of the anthropological knowledge, but that of bio-medical sciences.  So, the anthropologist situates him/herself vis-à-vis his study object in an unauthorized position in this field of study. The search for recognition within knowledge is reversed.  It becomes a strategy to validate the relativist epistemological foundations of anthropology within a field dominated by empirical knowledge, based on the presupposition of knowledge's objectivity of biological sciences, considered as the sole reference for scientific knowledge.4

It is worth recurring to an idea in a text by Lévi-Strauss, where he emphasizes what he called the universalism of French sociology, because of its close collaboration with all thought currents which had man or the study of man as their object.  This sociology, he says, "never considers itself as an isolated discipline, operating within its own domain, but, above all, a method and an attitude in face of human phenomena" (1947, p. 515). 

We may retain this idea, going back to a text previous to today's debate on the status of native knowledge in face of that of anthropology, to talk in other words, of the anthropological method as a means of looking at the world, not only as a perspective, but also as an attitude in face of human phenomena.  We intend here to argue that the anthropological study, within the field of studies on body, health and illness requires that its view-point - the definition of its theoretical and methodological perspective - comes together with an attitude on the part of the anthropologist vis-à-vis biological knowledge in order to establish the terms of a possible communication between anthropology and bio-medicine, a necessary attitude in face of the place of "higher truth" of biological knowledge in this field.  This means that there is an implicit specific political question to be confronted in the development of anthropological studies, and of the social sciences in general, within the field of health,  a dimension that becomes an epistemological problem in so far as its confrontation is a requirement to the construction of anthropological knowledge itself, in its own terms, in order to validate anthropological analysis as a form of knowledge on the body, illness and health, in itself, and not as a subsidiary knowledge, with lesser heuristic value.

From the problem so established, we may define an axis of differentiation in order to understand, in general terms, this field of anthropology through the position in which it stands before the biological sciences.  From this point of view, we may speak of two perspectives that correspond, in fact, to two watersheds in the anthropology that studies body, health and illness: "medical anthropology", subsumed in the logic of bio-medical knowledge and "anthropology of health" (or of illness), operating from a notion of culture constructed as another epistemological reference in relation to bio-medicine.

 

"Medical anthropology"

The so-called "medical anthropology" (or "ethno-medicine") has its mainstream in North-American anthropology, but is also present in British anthropology, and in general in the studies on health and illness in many countries.  In order to situate this school, we may trace its origin to the works of Good (1994), Kleinman (1980, 1995), Scheper-Hughes and Lock (1987), authors that define their field of work as "medical anthropology".5                 

Running the risk of simplification, inevitable when classifying different works under a common category, we may say that it is an anthropology with empirical basis that analyzes variations around conceptions of the body and illness and elaborates what may be considered as a rich inventory of that cultural variation, situating itself by reference to the official bio-medical system, often at its service.  It has an instrumental character in face of the needs of the official medical system.  From that perspective, anthropology operates as a translator of different cultural languages in terms intelligible for the bio-medical field, and vice-versa.

The notions of body and illness outside the field of bio-medicine have here the status of an "other".  They remain as part of an exotic domain relative to bio-medical references, while the latter are considered in absolute terms, naturalized, in a perspective that, restricted to an empirical level, reduces culture to a particular phenomenon.  Thus, that  anthropology, even when trying to place itself in a critical perspective in relation to bio-medical knowledge, walks in a parallel path, following it, so to say, for the notion of culture, considered as an essence, does not effectively mark a theoretical alternative to empiricist analyses on the body, health and illness that may open the possibility of an encounter of different perspectives.  Implicitly, there are reified images of the other, as in colonial narratives.  The language itself, where the term "medical" is an adjective of "anthropology", substantive, is a symptom of a relationship where one of the fields subsumes the other.  In Brazil, that perspective is found more often in health institutional spaces (public health, social medicine, etc.) and in publications in the area, because of the obvious practical and political implications of facing this asymmetry.6

In health institutions, anthropologists often deal with "other" cultural ways of thinking about the body, health and illness, as if this were a guarantee of an anthropological contribution to this area.  As if anthropology was defined by its object and not by the problem that constitutes it as a discipline and as a research method, that is the analysis of human phenomena - any human phenomena - as a cultural construction, which implies that the place of otherness cannot be fixed, for it is always a matter of perspective.  Lévi-Strauss (1962) called our attention to that risk, in a famous text on the presumed crisis of anthropology in face of the disappearance of the so-called "primitive" societies.

A difficulty - which is the basis of ethnocentrism - crosses the dissonance  of anthropology and bio-medicine and it has to do with the fact that western contemporary bio-medicine is the internalized (then unconscious) reference for the care of our own pains and sufferings.  Along this line of reasoning, Clavreul (1978), in his analysis of the "medical order", warns us to the problem of criticizing this order, for, as cultural subjects, "each of us is too solidary with medical discourse to the point of not embracing in advance its reasons".7

Not facing this ethnocentrism, which, as a cultural phenomenon,  belongs to the realm of the unconscious, results in a naïf search for complementarity, failing to take into account that the difference between anthropology and bio-medicine is not the object itself, but the gaze on the object.

Thus, medical anthropology is incorporated to bio-medicine, becoming what Le Breton (2001) called "residual anthropology", through the attempt at dividing objects between one and the other, eluding the tension that nourishes the search for the recognition of distinct knowledge.  When, in a reductionist division of disciplinary attributions, "other" cultures are not privileged, the reference to bio-medicine is divided within the same simplifying perspective.  This time, the "social" is considered a realm for medical anthropology (and sociology), while the "individual" is the attribution of biological or psychological knowledge.

The foundation of this division is the identification, which flows in this area, of the social and "collective" phenomena as the proper object of the social sciences, while bio-medicine and psychology, or psychiatry, have as their object the "individual", as if it was not, as much as the collective, a social category.  The social is reified as collective, becoming a "thing" atomized in a collective body, as an organism, closely following the Durkheim of The Rules of Sociological Method.  Both dimensions - social and individual - are reified and naturalized, not taking into account, on the one hand, the historical and cultural construction of the category "individual" (Dumont, 1993) and, on the other, the complexity of the "social" as a symbolic category.

Its object so conceived, anthropology could find its place in the realm of public health, social medicine or collective health, for this is the space of the "social" in the area of health, and the anthropologist would be a professional foreign to other health realms.  That "medical" anthropology thus confers to anthropology the place of a field of knowledge of the other - exotic - keeping bio-medicine outside the reach of cultural analysis.

Some time ago, Augé (1986) called attention to the theoretical weakness of medical anthropology that prevents it from giving the discipline's contribution to the field of health, for it spins around questions already settled in its internal discussion, leaving out of its reach those points where the anthropological study of illness could renew anthropology as a discipline.

Summing up the critique to that perspective, I refer to the work of Duarte (2004) and, in particular, to his review of the formulations of North-American medical anthropology about the so-called "nervous" diseases:

These works are crossed not only by the more diffuse conception that civilized subjects are those that operate with clear, distinct and rational notions about what is the body and what is the spirit or mind (by contrast to the knowledge of the nerves, that confuse these classifications), but also by the idea that contemporary psychological categories express what goes on with human beings, while systems as the nervous system are - only them - "cultural" or "symbolic" (Duarte, 1993, p. 51).

 

The anthropology of health

The second "school", that may be called anthropology of health (or anthropology of illness), is connected, above all, to a tradition that goes back to Marcel Mauss, and has in France its main place of origin and development (Augé, 1986; Augé and Herzlich, 1984; Laplantine, 1991; Le Breton, 2001).  Augé (1986) argues, for this "school", that there is only one anthropology, that deals with different empirical objects (health, illness, religion, kinship) without dividing itself into "sub-disciplines" and asks if these different observation objects before the anthropological gaze, by the end of its construction effort, do not constitute a sole object of analysis.

This is a pertinent question.  Following Augé, we should think not only about the contribution of anthropology to the field of health, but also how the anthropology of health and illness may help in thinking anew the object of anthropology.  What is at stake is not only the ethnographic inventory of different conceptions of health and illness and their practical consequences for treatment that nourish "medical anthropology", but also the theoretical question that passes through these studies in a field where the idea of culture faces, in a radical way - involving an attitude or political position - a knowledge that denies its own raison d'être, by postulating the primacy of the biological dimension of the phenomena under scrutiny, if not its exclusiveness.

Compared to the previous perspective, the anthropology of health, following the relativistic tradition of the discipline, considers all medical systems, as well as all discourses on the body, health and illness, as cultural categories, wherever they come from, due to the simple fact that they exist, and invests them with the same attention and interest (Laplantine, 1999).  In many senses, it returns to Marcel Mauss, to whom there is not a noble theme or a theme unworthy for science.  "Science" becomes itself an ethnographic object of study.  It is a matter of not  excluding beforehand from the reach of anthropological analysis any object, but treat them as cultural categories, which implies  a distance from the logic of the social world's hierarchies.

If anthropology accepts turning its attention only to what is outside bio-medicine, naturalizing it, or privileges what constitutes the "error", the defeat in that scientific field taken as an absolute category, it ends up by reproducing the constitutive divisions of the western symbolic universe.  Among these divisions is that which marks this world at least since the Renaissance and gives support to biological sciences and consequently to knowledge and practices of  bio-medicine: the split between the person and the human body, a split that, as it becomes real and concrete, evidences the ambiguities and moral tensions in which it has always been involved.

According to Le Breton (2001), that split is older than Cartesian dualism, that separates body and mind.  The latter concretizes and consolidates the previous split in the seventeenth century, but its historical root, its foundation, is the development of anatomy, based on the official practice of dissection of corpses, at the beginning of the fifteenth century.  For this author, the anatomists, particularly Vesalius, whose work De humani corporis fabrica dates from 1543, give rise to a distinction implicit in the western episteme of man and his body.  This is the source of the contemporary dualism that considers the body in isolation, in a kind of indifference relative to the person that inhabits it and which so clearly marks bio-medicine to this day.8

Among the most evident expressions of this cleavage in the contemporary world is organ transplant, whose difficulties that transcend questions of a purely technical nature, reveal the moral conflicts and injunctions that surround that cultural practice.

That was a decisive ontological change in the western world, in its conception of the person that allows and opens the way for the development of anatomy and physiology on which bio-medicine is based.  According to Le Breton (2001), this duality of body and person characterizes the modern conception of the body and dominates to this day.

If the most recognized conception of the body in our (western) culture is that which derives from anatomic-physiological knowledge, the construction of a notion of a split person, separated from its body, was required as a condition of possibility for the historical development of that knowledge, and the body came to be conceived solely in its biological dimension.  The body, separated from the person, is conceived as an attribute that today, given bio-technology resources, may be even modified.  Here, "the body is associated to having a body and not being a body", as shows Le Breton (2001) in his analysis of the body created by anatomy, from the Renaissance on.9

This is then what the anthropology of health deals with: the notion of the person, the conception of the human, the anthropos, a necessarily social and historical construction, presupposed in the many conceptions and practices that involve body, health and illness, in any realm of social life, in every time and space.  The object of the anthropology of health, therefore, is not constituted by the body, health and illness, but by what subjects, within a culture, think and live as body, health and illness.  As an anthropologist, the researcher assumes a perspective before his/her object.  Far from being an objective reality, what is a body depends always on the perspective - from within or without, above or below - from the one who carries it, who looks at it, on what is seen…

 So, it is easy to understand Marcel Mauss' decisive influence in this field of study, above all because of his formulations about the  person, the  feelings and the uses of the body - "corporal techniques" - as social constructions.  Not only Mauss, but French sociology in general (Émile Durkheim, Robert Hertz, among others) that, defining "the human facts" as its object, so far studied by medicine and psychology (as body, sentiments, death and illness) was pioneer in creating theoretical tools enabling us to understand these phenomena as social and cultural facts.

We may think of Hertz's well known study, The preeminence of the right hand, originally published in 1909, as emblematic of a perspective of a relation between biological and social knowledge.  The author considers the formulations of Broca on human anatomy, according to which there is a connection between the preeminence of the right hand and the higher development of man's left brain hemisphere. He quotes Broca,10 who says: "We are right-handed because we are left-brained"..11 Hertz inverts the phrase and asks instead: "Why not saying that we are left--brained because right-handed?"

Hertz intends to show that, although there is an anatomical basis for this asymmetry, right handedness is not a natural necessity, but an ideal.  For him, the difference in value and function between our body's sides cannot be explained by anatomy, for it has characteristics of a social institution and its explanation belongs therefore to sociology.  He then concludes that, if this organic asymmetry did not exist, it "would have to be invented", for it corresponds to a social value.

Hertz's statement appears valid to the present time when we think of the characteristics and definitions of the body, or its parts, that our society "invents" as moral justifications in face, for instance, of the new possibilities offered by bio-technology, particularly in aging and other corporal processes, as assisted reproduction, organ transplant, changes in sex, etc.   

 

The body

In order to be understood, the physiological experience of the body requires, therefore, a reference to the social categories that provide it meaning.  The body is constitutively symbolic.  Human existence is corporeal.  We are born, we grow up, we live, we get ill and we die in a body.  As Le Breton (2001) says, to be is to corporally move in a given space and time.  However, the way in which everyone lives its corporeal reality and conceives the body he/she inhabits depends on the notion of person, that itself derives from the collectivity whose part it is. 

When the bio-medical discourse speaks of a bodily pain, the tendency is to associate it to a neuro-physiological phenomenon.  This discourse admits there are social or psychological "components" in the experience of pain.  But it supposes a previous and autonomous corporeal existence that configures the notion of biological body, to which psychic and cultural factors are added.  Against this proposition, from the anthropological perspective, there is not a body outside of (or previously to) the symbolic register.  The social and cultural world does not intervene in a preexisting body, considered as "nature."  The body is a human reality because of the meaning it receives from the collectivity, meaning that flows, as was already said, from the notion of person (Sarti, 2001, 2003).

There is not such a thing as a previous corporeal existence, that is, a natural order previous to cultural intervention.  The body becomes human as it is constitutively inscribed in a symbolic system.

The objective reality biological sciences attribute to the body, that turn it into a suitable object for experimental observation is, in itself, a symbolic construction, required for the development of these sciences, as shown by Canguilhem (2006) in his critique, afore mentioned, of the bio-medical notions of  the "normal" and the "pathological".  If the biological sciences conceive the human body as an objective physical reality, separated from the subject inhabiting it, anthropological literature symmetrically offers us several ethnographic examples showing different ways of thinking about body structures and functioning, and also different conceptions of the frontiers that separate the body from its surrounding world, which posits anew the question of the body as a limit between myself and the other, as conceived in the western world.

Amerindian studies are a fundamental reference for the anthropology of the body and health, for they show the discontinuity among the human, animal and vegetal worlds as a cultural construction, and this has decisive implications for the conception and forms of dealing with corporeal existence (Descola, 1996, 2005; Lima, 2002).  These ethnographic data are particularly relevant for an anthropology of the body, for they allow for the deconstruction of one of the fundamental pillars that support the notion of the body in the western world, which is the duality nature-culture, associated to the consequent assumption according to which the biological body is part of the realm of nature.  These are data that allow for the relativization of bio-medical knowledge, as compared to other symbolic systems, disfiguring the truth status acquired by bio-medicine in what concerns the knowledge about body, health and illness.

Within the critique of the idea of bio-medicine's naturalized body, gender studies play an important role as they turn the social construction of man's and woman's body into a problem.  In relation to the question at stake - the terms of a possible communication between anthropology and bio-medicine - I refer to Laqueur's work (2001), whose research shows that, in the history of medicine, the differentiation of the sexes was defined in the eighteenth century when, according to him, "the two sexes" were invented, "founding gender", basis for the creation of gynecology as a medical specialty focused on the woman.  As shown by an abundant literature, this was the consolidation of a family model and a moral pattern on which it was based, through the control of women's body and sexuality (Rodhen, 2001).

Besides the notion of "nature", the notion of the "individual" is another of the critical axes around which develops the discussion of an anthropology of the body, within the perspective that postulates the radical need to distance oneself relative to our own cultural system's categories.

Body and individual are notions that go together in modern and contemporary western culture.  The atomized notion of "individual" as a representation of the "self" in modern western society was based on the body.  As referred to by Le Breton (2001), Durkheim, mentioning the need of an "individuation factor" in the constitution of the "self", says: "The body performs this role" (Durkheim, 1989, p. 331).

The conception of a "self" socially identified by the category "individual", limited by its corporeal existence, appeared only recently, even in the history of the western world.  As a social category, historically constructed among the modern cravings for freedom and autonomy, the individual tries to free him/herself from the chains of the traditional world, where he/she drowns in the collectivity.  Thus, according to Dumont (1993), the individual becomes a value.

As we know from Dumont's work, the triumph of individualist ideology that supports such representation of the person was historically expressed in the eighteenth century by the French Revolution in the Universal Declaration of Rights.  This process consolidated the modern conception of body and person, founding the representation of the self and its place in the social world.

The analysis of the notion of individual as a social category, configuring a value of modernity, is particularly present in the anthropological studies whose object is mental health, therefore, psychiatry and psychological knowledge in general. I emphasize Russo's definition of the "three subjects of psychiatry" that mark the tension around the modern individual with which this branch of medicine deals: the biological subject, "determined by its biological nature"; the citizen subject, "restrained by society's injunctions (by social and political oppression)"; and the subject of singularity, "singularized by its intra-psychic conflicts" (1997, p. 1).

So, it is within the tensions involved in the modern idea of subject/person/individual that we may situate illness, in face of a split of body and person that, while corresponding to the dominant representation of corporeal existence in the western world, will never be able to elude the ambiguities, conflicts and uncertainties that constitute it.

 

Illness

If, in any society, the notion of the body presupposes the notion of person, the conception of illness depends on both these notions.  Such as the conception of the body, illness classificatory systems are articulated in the social universe that constructs and expresses them.  They are symbolic constructions.

Among the considerable variety of ethnographically known representations of illness, involving many etiological and therapeutic models, we may distinguish, following Laplantine (1991), two non necessarily exclusive tendencies: the ontological model, that corresponds to medicine focused on the disease12, based on a physical model (here presupposed the idea of a "being" of the disease); and the relational or dynamic model, corresponding to a medicine focused on the ill person, based on a model that takes into account the internal dynamics of the organism as a whole, in its relation to the environment.

According to this classification, within the dominant conception of the body in contemporary western society (that separates body from person) the prevailing model is the ontological.  In a body separated from the subject, the disease is a strange and autonomous being, that "speaks" for itself.  So, another episteme, different from that which founds and supports contemporary western medicine (bio-medicine), also implies another conception of the person, distinct of that which separates body from person and  gives autonomy to the body as a biological entity, a matter to be unveiled through experimentation.

Canguilhem (2006) and Foucault (1977) figure among the philosophers that most radically criticized biological sciences' positivism.  Beyond the obvious affinity between them,13 Macherey (1993) calls attention to differences (even oppositions) in the view-points of these authors, relevant if we are to think about the possible forms of their dialogue with anthropology from the problems at stake in a parallel reading of both works: The normal and the pathological, whose original is from 1943, and The birth of the clinic, from 1963.  Both works address the question of the intrinsic relationship of life and death, or the ties between the live being to the mortal being, as it is experienced from the clinical experience of illness, but they do it in different forms.  The fundamental difference lies in the object to which each of them looks.

Canguilhem criticizes biology's objectivity from the concrete experience of the "live being", opening, according to Macherey, a "phenomenological" perspective of the game of life  taken in its biological dimension, in which  the essential normative character of life originates.  Canguilhem attributed to the human being a paradoxical state (Roudinesco, 2007), namely, that of being permanently touched by illness, itself inscribed in the normative character of life, polarized between positive and negative values.  On the other hand, Foucault writes of a historical birth, located in the development of the political and social process and thus making an "archeology" of medical norms seen from the medical side, and, acting behind it, of medical institutions, and not from that of the ill person.  Canguilhem turned his attention to the ill person that, for Macherey, is the great absence in Foucault's work.  To the latter, illness is subjected to the "medical gaze", a gaze that normalizes and is normalized.  Here, Foucault reproduces his analysis of the watching, controlling, and absolute gaze that chases his work and has its clearest expression in Discipline and Punish.14

Still following Macherey (1993), the concept of experience figures in both authors, but with different meanings.  For Foucault, it is not an experience of the live being, but a collective, anonymous, historical experience, from which springs the entirely non-individualized figure of the clinic.  Clinical experience is constructed as a norm, in a triangular structure: on the one hand, the ill person (object looked at), on the other the doctor (member of a "body", the "medical body"), acknowledged as that with the competence to be the subject of that gaze: the "medical gaze". The third position is that of the institution, that socially legitimates the relationship of the object of the gaze and the subject who gazes at.  

Because of this a priori historical form, previous to the concrete experience of illness, both the ill person and the doctor him/herself are neglected.  This historical structuring establishes the relation between live being and mortal being.  The corpse opened by dissection reveals the internal truth of illness, evidences the relation of doctor with ill person: there are not suffering subjects, there are structures that lead to suffering.  In the conditions of the clinical experience, death, as well as life, is not an "ontological and existential absolute" any more and, at the same time, it acquires an epistemological dimension: "as paradoxical as this may seem, it [death] 'illuminates' life" (Macherey, 1993, p. 291).

For Canguilhem (2006), the fundamental experience in the knowledge of illness is that of the ill person.  The central concept for his analysis is that of "live being", subject of an experience that exposes him/her, in an intermittent and permanent manner, to the possibility of suffering (Macherey, 1993).  Illness, part of life, is a way of being in life.  It expresses another way of living.  It therefore institutes a difference: "There is not such a thing as a fact that is either normal or pathological in itself.  Anomaly and mutation are not, in themselves, pathological.  They express other possible ways of living" (Idem, p. 113).

The Idea of cure leads to something non existent previous to the experience of illness, a new physiological state: "no cure is a return to biological innocence.  Curing is to create new ways of life, sometimes better than the old ones.  There is an irreversibility of biological norms" (Idem, p. 176).

We may detect an affinity of Canguilhem's thought and anthropological thought for the central place the question of difference has in both.  In Canguilhem, this question comes from his look at the concrete experience of the "live being" - that gets ill - thinking about illness, which leads him to attribute to the ill person a fundamental place in the knowledge of illness, a perspective that reverts the terms of knowledge and gives way for the critique of bio-medicine's ethnocentrism: science does not inform the clinic, it is the other way around.

Saying that "ethno-medicine's (or medical anthropology) object is still illness and not the ill person", Zempléni (1994) refers to the mentioned analytical possibilities of the English language, that distinguishes disease and illness, and says that this distinction recovers that of René Lériche, a French doctor, a pioneer in the bio-medical field, who, in 1936, distinguished between the "doctor's illness" and "the ill person's illness" (Lériche, 1936).  It was through the study of pain, whose knowledge cannot do without the ill person's experience, that Lériche arrived to the relevance of the ill person's knowledge of the illness.  It is to Lériche that Canguilhem pays homage in his study on the normal and the pathological, particularly when he says: "It was always accepted and it is today an unquestionable reality that medicine exists because there are people that feel they are ill and not because there are doctors that inform about their illnesses" (2006, p. 59).

The anthropologist's task thus becomes that of constructing a knowledge on health and illness that, not being a mere subsidiary of bio-medicine, may relate to it, for, as social scientists, we cannot ignore the discourse that founds western society's conception of our object of reflection - basis of the care of our own pains, illnesses and sufferings -, running the risk of an excessive self-reference, a defensive position that threatens not only the social reach of our endeavor, but even its heuristic value.

 

Concluding remarks

Concluding, I would like to emphasize the place of anthropology in the study of the body, health and illness from the view-point of what makes it a discipline within the field of the human sciences.  We may recur to Foucault, when he attributes to anthropology (ethnology), together with psychoanalysis, a singular place in that field, for the discipline is constituted in and through a confrontation: "Ethnology takes on its own dimensions in the historical sovereignty […] of European thought and of the relation that may confront it with all other cultures and with itself" (1992, p. 394).

Arguing that anthropology, like psychoanalysis, questions "not man him/herself, as may appear in the human sciences, but that region that makes possible, in general terms, a knowledge about man", Foucault attributes that which distinguishes it to the fact that "it is placed within the singular relation that western reason establishes with other (non western) cultures" and, from this on, it draws "the contour of representations that men, in a civilization, may formulate of themselves" (Idem, p. 395).  It is this way, in the constitutive tension of that being inside western rationality - on which bio-medicine founds and supports itself - and simultaneously face being outside it, in a relation of otherness, that anthropology moves itself in the scientific field that studies the body, health and illness.  A tension that depends on the fact that, if anthropology was born in the nineteenth century under the aegis of western universalist thought, it has been  firmly critic of the ethnocentrism and rationalism implicit in this thought.

Facing the founding character of this inevitable tension - a permanent move between the inside and the outside - anthropology may give an effective contribution to the studies of body and illness, as an alternative to bio-medical rationality, but keeping a constant vigilance.  The anthropologist may not yield to the overwhelming dominance of bio-medical  conceptions and practices in what involves the body, health and illness in our society, for he/she is, above all, an anthropologist, following his/her epistemological references and the debates that animate it, which places him/her, within the field of health and illness, in a position of resistance.

 

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1 I thank the careful reading and comments by Patricia Birman and Olgária Matos to the first version of this paper.
2 In the case of anthropology, that expansion shows its significance in the debates in both national and international meetings (Yearly ANPOCS (National Association of Graduate Studies and Research in the Social Sciences) Meetings, Brazilian Meetings of Anthropology and Mercosul Meetings of Anthropology, among others).
3 For the discussion, in Brazil, of bio-medicine (or bio-medical rationality) as a cultural reference that informs health conceptions and practices, as well as the notion of illness in the contemporary western world, see Camargo Jr. (1997; 2003).
4 That may be seen, for instance, in the definition of criteria for the evaluation of the scientific production of researchers in the area of health, that strictly follow the logic of biological sciences, not taking into account the distinct nature of the production of knowledge in the social sciences.  Scientists of both biological and social sciences are required to publish in the scientific journals evaluated according to bio-medical criteria, without acknowledging the difference, what generates a relative disadvantage in structural position for the social scientists, with significant problems in what respects, especially, research resources.
5 However, in spite of this self-definition, a good part of what characterized that school as here described, does not apply in totum to all the work of its authors, particularly to the important contributions by Arthur Kleinman and Margaret Lock.  A detailed analysis of this tendency implies considering the specific social and institutional contexts of this field, besides the researchers' profiles, which lies beyond this essay's purpose.
6 In Brazil, journals that publish anthropological articles in the perspective of "medical anthropology" are found mainly among those in the area of health, particularly public health.
7 In the original: "Chacun de nous est trop solidaire du discours medical pour ne pas en épouser d'avance les raisons" (p. 27).
8 If the dissection of corpses splits the human being in the seventeenth century, in the nineteenth it redefines its relationship to death.  It is worth mentioning here "the most beautiful pages" (according to Roudinesco, 2007), of Foucault's book (1977), Open some corpses, where he speaks about Bichat, a surgeon that, in the beginning of the nineteenth century, created, with his studies of pathological anatomy - in which he opened corpses - a new relation among life, illness and death.  Death is not an absolute anymore; science took it away from religion.  The crossing from life to death comes to be seen through physiological and pathological processes inscribed in living organisms.  "Instead of remaining what it had been for so long, darkness in which life is extinguished and  illness itself submerges, it [the death] is endowed, from now on, of a great illuminating power that dominates and unveils both the space of the organism and the time of illness" (p. 165).
9 In the original: "Le corps est associé à l'avoir et non plus à l'etre" (p. 47).
10 Paul Broca, French surgeon and anthropologist (1824-1880), student of the brain and the functions of language.
11 In the original: "nous sommes droitiers de la main, parce que nous sommes gauchers du cerveau" (p. 81)
12 The distinction between those two models corresponds to the distinction in the English language between disease and illness, stressed by American and British anthropologists who study health and human suffering. Illness refers to the state of being physically or mentally ill and disease applies either to a particular illness that someone "contracts" or "catches", or that affects a particular part of the body, centered mostly in its biological dimension.
13 Affinity to which Roudinesco (2007, p. 44) refers in her work on the French philosophers of the second half of the twentieth century.  Canguilhem was Foucault's advisor in his doctoral thesis (Madness and Unreason : History of Madness in the Classical Age).
14 It is worth noting Richard Sennett's comment in Flesh and Stone: The Body and the City in Western Civilization (1997), in a section of the introduction titled "A personal note", where he speaks of the influence of his friend Foucault in the work that was begun with him and changed direction after his death.  He says: "in one of his best known works, Discipline and Punish, Foucault imagined the human body asphyxiated by the power knot.  As his own body enfeebled, he tried to undo that knot; in the third volume of his History of sexuality, and in notes destined to the volumes he did not live to complete, Michel Foucault explored the body pleasures that do not allow for society's control.  His paranoia over controls, so important throughout his life, left him when he began to die" (p. 25).