Answers to commentaries: implications and challenges in the frontier of epidemiology

Jaime Breilh About the author

I have been asked to respond to the comments of three of the most important Brazilian critical thinkers with regard to my short essay about cyber determination.

In the first place, I am deeply thankful to the journal Revista Brasileira de Epidemiologia for providing its valuable platform to publish this enriching dialogue raised by the commentaries. Secondly, I must also thank my commentators for their deep insights which definitely add relevant arguments to better position a crucial debate for contemporary epidemiology.

An array of reflections arise from the crucial arguments posed by Ayres, De Oliveira, and Soares, all of which tend to complement my main thesis: the need to consolidate an innovative critical epidemiology paradigm; the resulting challenges for the construction of a counter-hegemonic conception of health and its determination; and, more specifically, the need to inscribe in this intellectual and political movement a new theory about the social space, power relations and the role of virtual cyberspace processes.

All the commentaries imply a recurrent agreement about the need to penetrate, with this opportunity, in the understanding of the rol of sociability, the existence of virtual forms of false sociability and their implications in the determination of unhealthy or healthy processes.

Hence, Ricardo Ayres suggests that in order to rethink present forms of sociability , heaviliky influenced by phenomena and resources of the cybernetic space, we should apply the intellectual arsenal of different schools of critical thinking, and imprpove our understanding of the varied forms of collective resilience which strive to overcome the forms of false sociability which are reproduced under capitalist social relations. In this effort to understand the mechanisms of intersubjective relations, he recommends to apply perspectives and categories which have proven useful in the fight for adolescents' health, such as those of "acknowledgment", "disrespect" and "non-acknowledgment". For this commentator, Honneth´s, acknowledgment/non-acknowledgment analysis as an essential tool for explaining the dynamic development of subjectivity, the construction of identity in interpersonal relations, the empowerment, awareness and collective self-esteem, needed for the exercise of rights and agency in the face of oppression.

Under this same rationale, Ayres comments on the importance of Lucács´s idea of reification ("cosificación") , both individual and social. Honneth extends this concept and underlines the significance of reification as an "oversight of recognition", which is reproduced by the people's practical connections, and that originates the objective identities we attribute to things, to the others, and to ourselves. Thus, as a result, we condemn ourselves to strict and unilateral identities, which deteriorate the possibilities of our critical reconstruction of reality.

The three commentators highlight in their analysis the existence of progressive expressions and critical possibilities in the global network. Marcos de Oliveira believes this is an understated element in my essay, which, according to him, denotes an "extremist" bias in my analysis. Both him and Cassia Soares insist on the need to recognize the collectivist and progressive uses that have been given to social networks and argue that my essay has not given enough space to the analysis of such options. I have no doubt about the relevance of this argument and the need to recognize that subordinate but emancipatory processes are vital. However, in turn, my reflections are stated from a cautious distance to avoid overestimating the real possibilities of individually based networking which in the long run has become a dead-end for many good willed enthusiasms, specially when the overwhelming power of big corporations that operate and control cybernetic domain imposes clear limitations for those progressive tendencies.

I would not deny the significance of the valuable arguments on substitutive sociability and about crosscurrent options for cybernetic agency exposed by my commentators. They surely bring us closer to understanding some options for alternative networks that could be historically sustainable. However, I worry that a unilateral emphasis on such "online" options, devoid of a careful analysis of the rotund asymmetry of power in the conduction of both "first and second life" processes, and apart from an strategic consolidation of "off-line" historical organizations of subordinate classes, could seriously undermine the commendable intentionality with the real viability of a liberating second life. In other words, if "the alternative" is formulated as the radical or unrestricted replacement of historical mechanisms of organization and political sociability, we could be giving up, without benefit of inventory, the most important real life social patrimony of the historical social struggle of workers, peasants, and citizens, and replacing them mechanically with virtual paths of substitutive sociability, of doubtful consistency as has been evidenced by the ephemeral organizational results of the Arab Spring, or the student outburst of Quebec or the momentary effects of the Occupy Wall Street movement.

In second place, this asymmetry aptly described by Marcos de Oliveira in my essay, between the ampler criticism of the hegemonic cybernetic trends and bad uses of cyber technologies, in comparison to a limited analyisis of alternative ways and uses, is not the result of non deliberate omission, on the contrary it implicates my deliberate decision of giving preeminence to the critical, anti-establishment analysis of "second life", or "on line life" as a privileged space for the reproductions of contents and practices associated with capital accumulation, social subordination and alienating massive consumption of the our people.

While I was writing the paper, I could not avoid thinking of the lessons learned by the Latin American Collective Health Movement, during similar moments of dilemma. In previous decades we had to judge the convenience of using tools created under the system´s logic and exploring if we could give them an emancipative use. Thus, for example, during the 1970s, the crossroad was presented In the field of the so-called "community medicine". The predominant such model of "community medicine" was a creation of technocratic international think tanks , to accomplish the goal of "health for everyone". We had to rule out if the institutional application of this "tool" could be used progressively for the health reform and advance of our university programs, or if, on the contrary, it would become a mediatization instrument of reformism and third class medicine for the poor. At that moment I joined those who thought that it actually was a negative strategy, so I wrote a text called "Community medicine: a new medical police", which was published by my friend Vicente Navarro in the International Journal of Health Services . Several friends and colleagues accused me of hypercriticism. History later showed us that the practice and implications of community medicine that were generalized in most cases resulted in a hegemonic practice of bad quality third calss services for the poor, and did not operate as a lever towards a new health system. Likewise, in the more recent years, some of us have been critical to the WHO doctrine of "social determinants of health" because we have considered it a distorted mediatization of the Latin-American paradigm of social determination of health; a substantial difference that has been analyzed in three consistent books. Here again, questioning our critical position, many colleagues argue that we have been hypercritical and that we should not assume a strategy of confrontation, but an eclectic recognition of both aspects as valid. We have thoroughly explained how the notion of "determinants" reproduces the fragmentary lineal reasoning of positivist epidemiology, becoming a renewed version of the functionalist rationale that justifies limited governance not an instrument of integral critique of the unhealthy intertwined processes of the market society.

Therefore, experience has showed us the real implications of these crossroads between the possible applications of certain instruments or lines of analysis and the ideal potential "progressive uses". They are most often solved in favor of power-dominant processes, and the good uses always end up as marginal attempts. Thus, based on these dialectical experiences, I have always preferred criticism without concessions, even at risk of overstating things, but assuring that our social ingenuity doesn´t end up making concessions to relentless and unhealthy processes of social subordination.

Nevertheless, I recognize the importance of carefully analyzing the potentialities of alternative ways and means for our "online-life" and the analysis of alternative uses for the new information and communication technologies.

An important issue these days, because in the last few years, there has appeared a thesis that the end of capitalism started when computing technology changed, evolving into what Allen Lance has called "post-capitalism". Many authors have mentioned that the end of the system is being operated by three main changes brought by information technology. First, by decreasing the need of human work, and removing the clear delimitation between work and leisure; second, because information is corroding the ability of the market to impose prices and of corporations to monopolize assets; and third, because it is allowing the historical ascent of associative production outside of the market.

Therefore, collective health and progressive public health face the serious responsibility of taking a clear side on these issues, of renewing our ideals, and projecting this kind of discussions to the struggle for healthier, sustainable civilization.

Publication Dates

  • Publication in this collection
    Out-Dec 2015
Associação Brasileira de Pós -Graduação em Saúde Coletiva São Paulo - SP - Brazil