O conceito de saúde: ponto-cego da epidemiologia?

Abstract

O trabalho faz uma avaliação da proposição de que o conceito de 'saúde' constitui um ponto-cego para a ciência epidemiológica, postulando que não há base lógica para uma definição negativa da Saúde, tanto no nível individual quanto no coletivo. Também analisa brevemente as tentativas de produzir uma "epidemiologia da saúde" em bases simétricas à epidemiologia dos riscos, bem como as abordagens econométricas que reforçam e complementam o repertório epidemiológico destinado à medida da saúde. Focaliza em mais detalhe a abordagem denominada DALY, considerada como protótipo da nova geração de indicadores de saúde, face à sua atualidade e crescente importância na definição de políticas de financiamento em saúde. Finalmente, constatando o fracasso das propostas metodológicas de avaliação direta dos níveis coletivos de saúde através de indicadores unificados, conclui com uma avaliação das perspectivas atuais da Epidemiologia no sentido da incorporação do objeto complexo da saúde na sua pauta teórica e metodológica.

Towards a Unified Theory of Health-Disease: I. Health as a complex model-object

“…To use an example from the health sciences, synergic effects of risk factors, produced by interaction processes, may be taken generally as sources of emergence in epidemiological systems. [6][7][8][9][10][11]31,70 In a study of gender, social class and race/ethnicity on prevalence of depressive disorders, 14 gender followed a pattern, confi rmed in different studies worldwide: women´s risk for depression is twice as high as men´s. Social class and race/ethnicity alone yielded low-risk estimates.…”

“…Considering the defi nitions of hierarchical interfaces and planes of emergence, a conceptual frame may be useful as a basis for integrating the contributions of health sciences and applied social sciences in a unifi ed theory of health. [6][7][8] This framework (Table 1) organizes the terminology used for categories of non-health available to different health sciences, in addition to distinguishing between the varied defi nitions of normalcy and health and their potential empirical descriptors. It implies an effort to translate Canguilhem's model into the theoretical specifi cations of Modes of Health.…”

“…The category 'disorder' refers to a disease without structural (anatomo-pathological) lesion, which occupies a level equivalent to the defi nition of disease in the clinical sphere. Private health, as well as individual health, object of an "epidemiology of health", 7 corresponds to 'illness', defi ned according to Canguilhem's model. In the individual instance, the descriptor "health status" is used to objectify the person's mode of health, and "feeling" refers to the intimate, private mode of health that cannot be made public.…”

“…Quantitative epidemiological descriptors (rates, coefficients) can deal with the subset's counter-domain (of sick population groups), equivalent to the population residue [1 -risk]. 7 The descriptor "health situation" corresponds to the notion of public health in Canguilhem, which may be called 'healthiness' in contrast to the idea of morbidity in traditional public health discourse. Finally, the modes of "social health", which are equivalent to the concept of sickness in interpretative medical anthropology, could be approached through Bibeau-Corin's systems of signs, meanings, and practices of Health.…”

“…54 For the past 15 years, colleagues and I have developed a conceptual framework for modeling health in the light of complexity approaches. [2][3][4][5][6][7][8][9][10][11][12][13][14][15]33 Results from this line of theoretical research allowed preliminary proposals of a Theory of Modes of Health 8 and the concept of Health-Disease-Care Integrals. 6 This paper is the fi rst of a series of essays intended to advance, revise, correct and abridge updated versions of such proposals, as well as to assess feasibility and possibilities for the integration/convergence/fusion of these approaches into a unifi ed theory of health-illness-sickness.…”