The authors reply
Os autores respondem
Nelson Filice de Barros; Everardo Duarte Nunes
Complementary and Alternative Medicines in Brazil: a series of issues
We thank each and every one of the discussants for their careful readings and provocative comments on our article. Some of the questions could be discussed immediately based on past research, while others merely call for general remarks. Still, the purpose of this reply is not to respond to every one of them, but to delve into those that we consider central to the current debates in the field of health.
Assuming deduction as the analytical perspective, we begin with a more general reaction to Paulo César Alves, recalling that in the conceptual matrix of social sciences in Brazil, the theme of Complementary and Alternative Medicines (CAM) has been present for several decades, although viewed differently. This issue is crucial for understanding the construction of social sciences applied to health, i.e., the social sciences in the field of disputes in health, since this understanding ensures room for another question, namely, why has such knowledge not been developed in a bigger way in the field of health? The author himself points to an important part of the answer when he underscores the propensity of our researchers to identify tensions and conflicts without considering the daily actions they simultaneously involve in the different healthcare arenas. We believe that this limited development is also due to the lack of bridges for developing the knowledge of social sciences in other fields. In other words, we do indeed have sufficient elements to demonstrate the social determinations on the health-disease-care process, but we still need to develop our skills "to build bridges to different audiences in academia, government, and the private employment sector. Building bridges involves bringing some congruence to the value orientations and priorities of sociological scholars and practitioners" 1 (p. 195).
In the reflections by Maria Cecília de Souza Minayo, we identify a second question, which is also of a more general dimension. Her discussion of symbolic efficacy, with referenced to one of the most important texts for health anthropology, refers us to the discussion on the construction of symbols and their process of "positivity" in the field of culture. Based on the principle that the seeds of the historical process in the near and distant future lie in culture, and that the social structure is maintained in the beliefs that sustain the elements of this culture, we identify some facilitating factors for understanding CAM in the field of health and in the current civilizatory pattern. Based on the civilizational issue, we contend that the 1960s counterculture was sufficient to unveil the dogmatic defense of efficacy and efficiency and the consensuses constructed in Western culture. Within the field of health in its more specific dimension, it becomes possible to glimpse the difficulty in the coexistence of different symbols of efficacy and efficiency, since in a culture of theocentric and monologic rationality, it would hardly be possible for the official and alternative (or the nuclear and the marginal) to coexist.
Philip Tovey presents a set of rather complex issues that can be seen as an agenda for the development of a sociology of CAM. However, the issue of the ability of CAM to act as symbols of distinction is fundamental for developing the discussion from the previous paragraph. Thus, once again within the field of health, it becomes possible to glimpse a new tension under way between the professionals who assume the risk of delving into "marginal" elements to treat social strata who consume such practices as a form of distinction and those who assume the risk because they trust in the efficiency of other care and cure practices for the strata that are most dependent on state health services. This interactional process reveals the construction of conceptual sets and evidence, much of which is non-scientific, acting as the cause and consequence of the growing use of CAM in different societies. We will have no way of knowing whether this is "old wine in new wineskins", but sociologically we can measure the process of structuring, institutionalization, conceptual precision, and efficacy of the symbols surrounding CAM.
However, as Maria Julia Paes da Silva (p. 2033) asks, "Would the 'expansion' of studies that encompass these practices be an attempt to make official medicine more effective?" The answer is quite complex, and we believe it cannot be posed exclusively, because if we limit ourselves to the gains achieved by the biomedical model, we can see a process of continuous and "spectacular" development: from the last decades of the 19th century, with bacteriology, to the spread of therapeutic and diagnostic technology and on to organ transplantation and the analysis of genetic determinants; for this dimension of the official healthcare and cure model from Western culture, CAM will bring few changes. However, if we look at the effects of this previous development on people's lives and health needs, we can state that the spread of CAM has brought important changes in the locus of care, the exercise of comprehensiveness, the expansion of autonomy, and self-knowledge in the health-disease-care process.
The complexity of the previous response is highlighted in a different way by Andrea Caprara (p. 2035) when she states that "the growth of modern medicine should have been accompanied by the disappearance of (or at least a reduction in) Complementary Medicine ... We are instead witnessing the opposite phenomenon (...) represented today by the medical humanitiesthat introduce aspects of human sciences in training and medical practice belonging to various artistic expressions ...". Thus, are the debate and actions concerning humanization a consequence of or an adjustment to the alternative perspective from the 1970s? Again, we face the difficulty of historically determining the beginning of a social project, but an initial sociological excavation allows us to state that to humanize relations was one of the central objectives of the 1960s counterculture, since it already showed that high-technology as expressed in the machine does not form the human capacity to listen, connect emotionally, and become personally involved.
The last comment, though no less important, by Russel Parry Scott, dwells on the specific issue of CAM as a category, subsidiary to the scientific one. We consider this aspect less general, because it shows the mark of the internal debates in the field of health, based especially on the alternative logic measured by the conjunctions "or ... or" and the notion of exclusiveness. We understand the concern in this reflection, that the place "in the second row" may not allow the existence of other medical rationalities or even alternative treatments, and that it is crucial to keep digging in search of the words and things from non-hegemonic cultures. At this juncture of the historical process in which the use and recognition of CAM is growing in various societies, we believe it is crucial to work with polysemy, focusing gazes on technical and symbolic interactions.
As we seek to name the differences and recognize the identities of the same concept in different spaces of knowledge and practice, we are pursuing an understanding of how value is generated in relation to a theme within a field, in addition to the production of new truths and evidence in structures and cultures. There is no finished model for this, but perhaps the concept of interculturalness 2, which is not new and which takes place at the juxtaposition of the notion of interaction (from micro-sociology) with that of culture (dear to anthropology, as a founding principle, since it is intended to operate with spaces and times that allow cultural expression) may favor the encounter (beyond the contact), may foster knowledge and recognition of different cultures, accepting difference as a positive factor that enriches social surroundings, and may recognize conflicts in a positive way, not denying their existence, which would be naïve, but assuming them as the motor force for change towards a less unequal civilization.
1. Perlstadt H. Accreditation of sociology programs: a bridge to a broader audience. Can J Sociol 1998; 23:195-207.
2. Mendez M, editor. Orientaciones para la interculturalidad, valores culturales dominantes. Barcelona: Universitat Autónoma de Barcelona; 1997.