ARTIGO ARTICLE 701

The concept of health and the difference

between prevention and promotion

O conceito de saúde e a diferença

entre prevenção e promoção

Dina Czeresnia 1

1 Departamento de Abstract In this article the author presents a point of view which she considers central to un-
Epidemiologia e Métodos
derstanding the difference between prevention – associated with the traditional discourse of
Quantitativos em Saúde,
Escola Nacional de Saúde public health – and health promotion, an idea in connection with which proposals are now be-
Pública, Fundação ing presented for rethinking and redirecting public health practices. This perspective relates to
Oswaldo Cruz.
the limits of the health and disease concepts in relation to the concrete experiences of health and
Rua Leopoldo Bulhões 1480,
Rio de Janeiro, RJ illness. On the one hand, practical awareness of this limit implies far-reaching changes in the
21045-900, Brasil. way scientific knowledge is related to (and used in) the formulation and organization of health
[email protected]
practices; on the other, health promotion projects also avail themselves of the concepts guiding
the discourse of prevention. This leads to certain difficulties that appear as inconsistencies or
gray areas in the operationalization of promotion projects, which do not always succeed in as-
serting their nature as distinct from traditional preventive practices.
Key words Prevention; Health Promotion; Complexity; Epidemiology

Resumo A autora apresenta uma perspectiva que considera fundamental para a compreensão
da diferença entre prevenção – associada ao discurso tradicional da saúde pública – e promoção
da saúde, uma idéia dentro da qual propostas estão sendo apresentadas para repensar e redire-
cionar as práticas em saúde pública. Essa perspectiva tem a ver com os limites dos conceitos da
saúde e da doença em relação à experiência concreta das mesmas. Por um lado, a consciência
prática desse limite implica em mudanças abrangentes na maneira pela qual o conhecimento
científico se relaciona com, e é usado para, a formulação e organização das práticas sanitárias;
por outro, os projetos de promoção da saúde também lançam mão dos conceitos orientadores do
discurso preventivista. Isso leva a certas dificuldades que aparecem como inconsistências ou
áreas nebulosas na operacionalização dos projetos de promoção, que nem sempre conseguem se
diferenciar das práticas preventivas tradicionais.
Palavras-chave Prevenção; Promoção da Saúde; Complexidade; Epidemiologia

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702 CZERESNIA, D.

Introduction practices, rooted in the effective utilization of

scientific knowledge. Medicine was structured
This paper highlights one of the problems on positive sciences and considered its man-
emerging from the very framing of medicine ner of apprehending its object to be scientific
and collective health, with new relevance today (Mendes-Gonçalves, 1994). The scientific dis-
in the discussion that seeks to differentiate be- course, specialty, and institutional organization
tween the concept of prevention – associated of health practices were circumscribed by ob-
with the traditional discourse of public health jective concepts, not of health, but of disease.
– and that of health promotion – another tra- The concept of disease was built on a re-
ditional notion, but currently pivotal to ap- duction of the human body, based on morpho-
proaches for rethinking and redirecting public logical and functional constants defined by
health practices (MacLean & Eakin, 1992). The such sciences as anatomy and physiology. “Dis-
development of scientific, and particularly ease” is conceived as endowed with its own ex-
medical, rationality brought enormous power ternal reality, prior to concrete alterations in
to bear on constructing representations of re- the bodies of the sick. The body is thus discon-
ality, in disregard of one fundamental consid- nected from the whole set of relationships that
eration: the limits of concepts in relation to re- constitute the meaning of its life (Mendes-
ality. For health, such limits are those of the Gonçalves, 1994), even though medical prac-
health and disease concepts vis-à-vis the actu- tice enters into contact with concrete human
al experiences of health and illness. beings and not just with their organs and func-
Building an awareness of this limit lies at tions (Canguilhem, 1978).
the root of current discursive changes in the One issue is that public health defines itself
health field, highlighting that to reflect on as responsible for promoting health, while its
health in all its complexity involves far more practices are organized around disease con-
than overcoming obstacles internal to scientif- cepts. Another is that its practices tend not to
ic production, in order to propose concepts consider the distance between the concept of
and models that are more inclusive and com- disease (a mental construct) and falling ill (a
plex. It is not a matter of proposing a “new” sci- lived experience), thus substituting one for the
ence, but of the need to construct discourses other. Concepts of disease shape specific forms
and practices that succeed in establishing a of intervention. The concept of disease is used
different relationship with all forms of scientif- not only as if it could speak for the concrete
ic knowledge. fact of falling ill. Most importantly, it produces
Based on this thinking, I propose a point of concrete practices that are represented as able
view that endeavors to demarcate the differ- to respond to the latter in its entirety.
ence between prevention and promotion in Edgar Morin, in O Problema Epistemológi-
health. The goal is also to gain a better under- co da Complexidade (The Epistemological Prob-
standing of some of the difficulties that appear lem of Complexity), highlights that a concept
as inconsistencies, contradictions, and gray ar- cannot adequately replace something far more
eas in the operationalization of health promo- complex. He relates complexity to the “diffi-
tion projects, which do not always succeed in culty of thinking, because thinking is a strug-
clearly differentiating themselves from tradi- gle with and against logic, with and against
tional preventive practices. the concept”; that is, the “difficulty of the word
that attempts to grasp the inconceivable and si-
lence” (Morin, s.d.:14). The word, although an
Health, science, and complexity elaborated form of expression and communi-
cation, is insufficient to grasp reality in its en-
Public health/collective health is defined tirety.
generically as the field of knowledge and insti- Human thinking developed in two direc-
tutionally organized practices aimed at pro- tions: towards depth, reduction, and narrow-
moting the health of populations (Sabroza, ing, and towards breadth, inclusiveness, and
1994). The knowledge and institutionalization extension of frontiers. Modern scientific think-
of public health practices are shaped in articu- ing tends towards reduction, taking up the
lation with medicine. Although going beyond challenge of attaining maximum precision and
the mere application of scientific knowledge, objectivity by translating events into abstract,
health practices have been represented as fun- calculable, and demonstrable schemata. The
damentally scientific technical practices. This language of mathematics is deemed capable of
representation cannot be considered simply a expressing the universal laws governing phe-
mistake, but rather an essential aspect of these nomena. The elements of events that words –

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 THE CONCEPT OF HEALTH 703

or, more precisely, scientific concepts – have book A Paixão Transformada (Passion Trans-
been unable to encompass tend to be consid- formed), showing how fiction is revealing “be-
ered errors or anomalies. The objective word’s cause it speaks of the hidden aspect of medicine
meaning has been presented in lieu of the and illness” (Scliar, 1996).
thing itself, the sensible aspect of which has Scientific medical discourse does not con-
been considered non-existent. template the broader signification of health
Reference to occurrences in their entirety and falling ill. Health is not an object that can
highlights the mutilating aspect of knowledge, be constrained within the field of objective
an issue raised ever since this way of grasping knowledge. It does not translate into scientific
reality came into being. In the contemporary concept. The same goes for the suffering that
world, the problem has certainly become more characterizes illness. Even Descartes, consid-
explicit as a result of impasses generated by ered the first to formulate the mechanistic con-
progressive fragmentation of knowledge. The cept of the body, recognized that certain parts
need to integrate the parts has arisen within of the living human body are accessible exclu-
analytical logic. How can information and sively to the owner (Caponi, 1997). This aspect
knowledge be integrated when they have been was considered and analyzed in depth by Can-
constructed in a quest for increasing depth? guilhem (1978) in Le Normal et le Pathologique.
Scientific thinking was presented with the In a more recent study, this author affirms the
challenge of striving for breadth, of valuing an concept of health as vulgar – having to do with
understanding of interaction among parts, to- each of our lives – and a philosophical issue,
wards unity and totality. The question of com- distinguishing it from a scientific concept (Can-
plexity emerged in scientific discussion as the guilhem, 1990).
possibility of explaining reality or living sys- Nietzsche, for whose philosophy vital things
tems through models seeking not only to de- provide a basic point of view, states the follow-
scribe elements of objects, but particularly the ing in relation to medicine and philosophy, re-
relations established among them. It became vealing the breadth of all that is evoked by the
evident that there were different levels of orga- term health: “I am still waiting for a philosoph-
nization in reality, each with its own emerging ical doctor, in the exceptional sense of the word
qualities. However, this endeavor found its lim- – a doctor who looks after the overall health of
it in the fact that reality is unspeakable, point- people, time, race, humanity – who will even
ing to how the construction of any model is in- once have the spirit to take my suspicion to the
evitably reductive. limit and venture the proposition: all of philos-
Health and falling ill are ways by which life ophizing to this day has not dealt with ‘truth’
manifests itself. They are unique, subjective ex- but with something else; call it health, future,
periences; words cannot recognize and signify growth, potency, life...” (Nietzsche, 1983:190).
them entirely. Yet the sick use words to express What does this approximation among med-
their illness. Physicians also use words to give icine, literature, and philosophy show if not ev-
meaning to their patients’ complaints. In the re- idence that, as Edgar Morin pointed out, objec-
lationship among the concrete event of falling tivity cannot exclude the human spirit, the in-
ill, the patient’s words, and those of the health dividual subject, culture, society? Medicine
professional, tension arises that leads back to was also considered an art. However, through-
our main question: the tension between the out its historical development it has hegemon-
subjectivity of illness and the objectivity of ically tended to identify with a belief in the om-
concepts assigning meaning and proposing in- nipotence of technique based on science. The
terventions to deal with that experience. gap between the singular experience of health
Complaints and symptoms reported by the and illness and the opportunities for knowl-
ill, loaded with emotion, are translated into edge of that experience have not been properly
neutral, objective language. The shortcomings recognized. This has led to a major problem in
of medical text in reflecting this broader di- historically shaping the use of scientific con-
mension of human suffering drew medicine cepts to instrumentalize health practices. Sci-
closer to literature. Through literature, count- entific truth predominated almost exclusively
less physicians were able to express human in representations of both reality and (most
suffering beyond the limits of the objectivity of importantly) health practices.
scientific discourse. Writers like Thomas Mann Unlike literature, scientific thought mis-
and Tolstoy described the human condition in trusts the senses. In developing a scientific con-
relation to illness and death as few others have cept, immediate contact with reality appears as
succeeded. This same theme is developed by a confused, provisional datum requiring a ra-
another physician-writer, Moacyr Scliar, in his tional effort of discrimination and classifica-

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704 CZERESNIA, D.

tion (Bachelard, 1983). Displaced from the struct a unifying discourse. What is reaffirmed
senses, scientific explanation constructs propo- is the need to revalue approximation – in ac-
sitions guided by planes of reference outlining tion – among essentially different forms of lan-
and confronting whatever is indefinite and in- guage, enabling them to complement one an-
explicable (Deleuze & Guattari, 1993). Scientif- other. The issue is to consider the truth value
ic construction cannot escape the need for a of scientific concepts in a relative light – to
circumscribed plane of reference. Within these make use of them, but not to believe in them
limits, explanation becomes possible by creat- absolutely – thus opening up channels for val-
ing operative resources to deal with reality. To orizing the relationship between sensibility
accept the limited domain of scientific thought and thought, without relinquishing our under-
thus qualifies its relevance, besides establish- standing of scientific knowledge, reinstating
ing a restriction, since this limit is illusory, and the importance of the role of philosophy, art,
no objective explanation can deny the exis- and politics. The effort is to build a new rela-
tence of mysterious, inexplicable, or unsayable tionship with the truth that will permit “wis-
things. dom to be found through and beyond knowl-
The issue is that the discourse of modernity edge” (Atlan, 1991:18).
has not taken this restriction into account. It is not by discovering some novelty, but by
Considering the limit on scientific construc- renewing the issues that modernity and en-
tion and its inevitably reductive character, one lightenment thought were smothered. While
can say that no concept, or system of concepts, continuing to use scientific knowledge and
can expect to account for the unity characteris- seeking to extend the possibilities of existing
tic of singularity. Concepts express identities, models, we cannot block the channels that
while the singular unit is an expression of dif- make us sensitive to reality. What we need is to
ference. However much explanatory potential recover old philosophies that have been forgot-
a concept may have and however operative it ten and sidelined by disproportionate belief in
may be, it is unable to express the phenome- reason and man’s power to control and domi-
non in its entirety; that is, it cannot represent nate. The aim is not truth, but happiness, wis-
reality. When one constructs a coherent, logical dom, and virtue (Atlan, 1991). Health also, and
explanatory system of explanation, one enclos- medicine itself, are concerned – as asserted in
es reality in a reduction. One can thus concede the above quote from Nietzsche – not with
that to accept this mental construct as capable “truth”, but with “… future, growth, potency,
of replacing reality mutilates the possibilities and life”.
for grasping reality via the senses. This issue is structural to the field of public
The point is not to question scientific health and lies at the root of what we call its
thought as limited and reductive, but rather to “crisis”. This aspect is fundamental in order to
criticize the point of view that denies the limits situate ourselves in the context of contempo-
on scientific construction. This denial is ex- rary changes in public health discourse and,
pressed, on the one hand, when scientific truth from the standpoint of this article, to properly
is taken as dogma and becomes insensitive to understand what differentiates prevention and
what is inexplicable, to what has not been ren- promotion in health. The discursive transfor-
dered into concepts. It also occurs when sci- mations are not only internal to the logic of sci-
ence is required to account for what is not entific discourse, but most importantly they re-
proper to it. No science can account for singu- define the limits and meanings of knowledge
larity, no matter how many new complex mod- produced in shaping health practices and con-
els are constructed to explain reality. Attempts sequently in the formulation of training pro-
to account for singularity establish new rela- grams for health professionals. The proposal is
tions between whatever knowledge is con- for a new way of using scientific rationality to
structed through concepts and models and the explain reality and, chiefly, to act. This process
singular occurrence it is intended to explain. entails more radical transformations than a
The emphasis here is the need to reassess the change within science, as they have to do with
limits on science in order to revalue and broad- building a world view capable of interfering in
en interaction with other legitimate ways of the enormous power that scientific rationality
grasping reality. wields in constructing representations of reality.
As we have seen, philosophy and literature
have always been complementary to medicine,
albeit marginally. When the primacy of scien-
tific objectivity is questioned today, it cannot
be to propose imploding these frontiers to con-

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 THE CONCEPT OF HEALTH 705

Public health and the difference services for the promotion, protection, and recu-
between prevention and promotion peration of health, at all levels, to all inhabi-
tants of Brazilian territory, leading to the full
To prevent means “to forestall or thwart by pre- development of the individual human person”.
vious or precautionary measures; provide be- Although this undeniably constitutes
forehand against the occurrence of (something); progress, this positive concept entailed a new
make impracticable or impossible by anticipa- problem at both the theoretical and practical
tory action; stop from happening” (New Shorter levels. By considering health in its full sense,
Oxford English Dictionary – Oxford University we are dealing with something as broad as the
Press, 1997). Prevention in health, according to notion of life itself. Promoting life in all its mul-
the classic work by Leavell & Clarck (1976:17), tiple dimensions involves measures at the
“calls for action in advance, based on knowl- overall state level and the singularity and au-
edge of natural history in order to make it im- tonomy of individual subjects, which cannot
probable that the disease will progress subse- be made the responsibility of an area of knowl-
quently”. Preventive actions are defined as in- edge and practices.
terventions directed to averting the emergence This official recognition of the medicine-
of specific diseases, reducing their incidence based public health model’s limits, given that it
and prevalence in populations. The discourse should be integrated with environmental, so-
of prevention is based on modern epidemio- cial, political, economic, and behavioral dimen-
logical knowledge. It aims to control the trans- sions, as well as with biology and medicine,
mission of infectious diseases and reduce the is an undeniable milestone (Carvalho, 1996).
risk of degenerative diseases or other specific Measures proper to health systems should cer-
ailments. Health prevention and education tainly be articulated with other sectors of disci-
projects are structured by circulation of scien- plines and government policy responsible for
tific knowledge and normative recommenda- the physical, social, and symbolic dimensions.
tions to change habits. However, this relationship between inter-sec-
To promote means “to further the develop- torality and specificity is a problematic field
ment, progress, or establishment of (a thing); that must be trodden with care, because there
encourage, help forward, or support actively (a is enduring tension between defining the lim-
cause, process, etc.)” (New Shorter Oxford Eng- its between the specific competence of mea-
lish Dictionary – Oxford University Press, 1997). sures in the health field and the necessary
Traditionally, health promotion is defined openness to integration with various other dis-
more broadly than prevention, since it relates ciplines. If specificity is not achieved by a disci-
to measures that “are not directed to a given pline, it must be based on delimitation of the
disease or disorder, but serve to increase overall problems, making it possible to implement ef-
health and well-being” (Leavell & Clarck, 1976: fective practices.
19). Promotion strategies emphasize changing In the context of implementing health prac-
the conditions of people’s lives and work, which tices, there is ongoing tension between two de-
form the structure underlying health problems, finitions of life: first, as our subjective experi-
calling for an inter-sectoral approach ( Terris, ence, and second, as the object of life sciences,
1990). studying physical and chemical mechanisms
Realization that the main determinants of structuring the cognitive foundation for inter-
health are external to the treatment system is ventions by medicine and public health. Ob-
not new. However, official formulation of pub- jective, operational health care interventions
lic health discourse to positively affirm health were formulated on the basis of concepts and
is quite recent. The International Conference theories concerning biological or psychologi-
on Health Promotion, held in Ottawa (1986), cal specifics. Any theory is reductive and inca-
postulated the idea of health as quality of life pable of accounting for all health and illness
resulting from a complex process conditional phenomena. In conceiving of the subject’s uni-
on several factors: diet, social justice, ecosys- ty, the most one can aspire to is to express it as
tem, income, education, etc. The broad con- “bio-psycho-social integration”, continuing to
cept of health came to the fore in Brazil that make itself manifest in a fragmented manner
same year and was incorporated into the Re- by way of concepts that do not easily converse
latório Final da VIII CNS (Final Report of the with each other. While living matter is more
8th National Health Conference, 1986 – MS, complex than the concepts that endeavor to
1986): “The right to health means the state’s explain it, operative interventions are made
guaranteeing decent living conditions and uni- possible through concepts. There is no way of
versal and egalitarian access to measures and producing alternative forms of health care that

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706 CZERESNIA, D.

do not seek to operationalize concepts of health prevention and promotion is not always clearly
and disease. affirmed or exercised.
This demarcation applies not only to the The idea of promotion involves strengthen-
constraints on specific health care action (i.e., ing individual and collective capacity to deal
social conditioning factors in the inter-sectoral with the multiplicity of factors that condition
dimension), but also to the limits of the objec- health. Promotion goes beyond applying tech-
tive concepts shaping the logic of interventions niques and norms, recognizing that it is not
(i.e., singularity and subjectivity in the con- enough to know how diseases function and to
crete fact of falling ill). In this sense, Canguil- find mechanisms to control them. It has to do
hem highlights the recognition that the neces- with strengthening health by building a capac-
sary concern with the subjective body should ity for choice, using knowledge to discern dif-
not lead to any obligation towards liberation ferences between (and singularities in) events.
from the tutelage of medicine, which is held to In the context of change in traditional pub-
be repressive. “Recognition of health as the lic health approaches, the approach by Castel-
body’s truth, in the ontological sense, can and lanos (1997) to the concept of health status al-
should admit the presence, as both a boundary lows us to broaden our understanding of health
and barrier, of truth in the logical sense, i.e., of promotion as an idea. Health status is defined
science. The body lived is certainly not an object; according to the options of the social actors in-
however, for man, living is also knowing” (Can- volved in the process. It cannot be understood
guilhem, 1990:36). “apart from the intentionality of the subject
It is doubtless fundamentally important to that analyzes and interprets it” (Castellanos,
value and create ways to broaden channels of 1997:61). Under the health status concept,
receptivity to the senses. The point of depar- health needs are differentiated from health
ture and reference for the experience of health problems. Needs are formulated by objective
and illness is the body’s prime intuition. How- analyses and procedures. Problems require a
ever, if used without reification, reason medi- more complex approach, shaped by choosing
ated by scientific knowledge enables intuition priorities involving the actors’ individual and
to be broadened and, most importantly, serves collective subjectivity in their day-to-day activ-
as “both an instrument for dialogue and a pro- ities (Castellanos, 1997).
tective barrier” (Atlan, 1991:13) for the singular In the context of change in scientific dis-
experience of falling ill. Scientific knowledge course that surfaced in collective health some
and the operative opportunity of technique in ten years ago, there emerged a recognition of
health practices should be used without caus- values like subjectivity, autonomy, and differ-
ing a disconnection from sensitivity in rela- ence. In understanding health and disease
tion to our own bodies. The challenge is to be processes, there was an effort to reinterpret the
able to transit between reason and intuition, meaning of such concepts as subject and na-
knowing how to view knowledge in a relative ture (Costa & Costa, 1990), while calling into
light without ignoring its importance, while question approaches that restricted processes
broadening the possibility of solving concrete to either the biological dimension or generic
problems. and structural determinants (Fleury, 1992).
It is precisely here that the radical – and at As discussions advanced within the field, it
the same time very small – difference between became clearer that reflecting on health in a
prevention and promotion in health stands complex manner does not mean incorporating
out. It is radical because it entails far-reaching a new discourse that migrates from the pole of
change in the way knowledge is interlinked objectivity to the pole of subjectivity, from the
and used in formulating and operationalizing universal to the singular, from the quantitative
health practices, and this can only truly occur to the qualitative, etc. It is not simply a ques-
by way of a transformed world view, as dis- tion of opting for values that were suppressed
cussed above. It is very small because the prac- during the development of modern scientific
tices of promotion, just like those of preven- rationality, and now to suppress those that for-
tion, use scientific knowledge. Health promo- merly were hegemonic. It is thus not an issue
tion projects also rely on the classic concepts – of constructing new perspectives that continue
disease, transmission, risk – that guide the pro- to reproduce old oppositions, but to learn how
duction of specific knowledge in health and to transit between these different levels and
whose rationality is the same as that of preven- ways of understanding and apprehending real-
tion discourse. This can lead to confusion and ity, taking as a reference not systems of thought,
a lack of differentiation between the practices, but the events that mobilize us to elaborate
mainly because the radical difference between and intervene.

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 THE CONCEPT OF HEALTH 707

To properly understand how promotion dif- Epidemiology and health promotion

fers from prevention is precisely to be aware
that the uncertainty of scientific knowledge is The integration of epidemiology and health
not simply a technical limitation which can be promotion lies in the problematic field ana-
successively overcome. Achieving health is a lyzed in this article. What has been said about
question not only of survival but of qualifying the difference (and similarity) between preven-
existence (Santos, 1987). It refers one to the so- tion and promotion also has to do with the use
cial, existential, and ethical dimension, to a of epidemiological concepts, which are the ba-
path of its own that refers to concrete situa- sis of preventive public health discourse. It is
tions, to an engagement and active commit- not an issue of “accusing” the reductive aspect
ment by subjects who devote their uniqueness of these concepts as a limit to understanding
to placing what is known at the service of what the complexity of health and disease processes
is not known in the search for the truth that in populations or to shaping public health
emerges in lived experience (Badiou, 1995). practices. Rather, it is a matter of being clearer
Therefore, thinking in terms of health promo- about the limits of these concepts, fostering di-
tion is knowing that changes in behavior are rect attempts to improve methods and to con-
oriented simultaneously by what is known of struct new concepts and use them in a more
deterministic conditions and by the clear real- integrated and appropriate way for the inter-
ization that not all of them are known, nor will ests and needs of structuring health policies for
they ever be (Atlan, 1991). promotion.
Practical awareness of the limits of knowl- Epidemiological knowledge plays an unde-
edge means laying no claim to a new scientific niably central role in shaping public health
theory that can formulate a discourse capable of practices. The traditional discourse of preven-
unifying all the dimensions involved in health. tion suffered from the theoretical poverty and
Promoting health involves choice, and this is hegemony of mechanistic, linear logic in the
not really the sphere of knowledge, but of value. conceptual development of epidemiology. Such
It is linked to processes that are not expressed problems have been revealed by existing cri-
by way of precise, easily measured concepts. tiques of the epidemiological concept of risk
Terms like “empowerment” (Eakin & MacLean, (Goldberg, 1990; Almeida-Filho, 1992; Castiel,
1992) and “vulnerability” (Ayres et al., 1997) are 1994; Ayres, 1997). What values are produced
being developed and used increasingly in the by representations formed through this con-
context of health promotion proposals. These cept? What meanings are generated socially
“quasi-concepts” not only permit transdiscipli- when habits and behaviors are identified as
nary approaches by linking with concepts from risks to health?
other areas, but they are open to the multiple The formal aim of risk analysis is to infer
meanings emerging from the consideration of causality, to assess the probability of disease
difference, subjectivity, and singularity in indi- events in individuals and/or populations ex-
vidual and collective health occurrences. posed to given factors. Nonetheless, despite
However, this openness continues to take proposing to measure individual or collective
the concepts that shape the specificity of the risks, what the risk model’s mathematical
public health field as a reference for dialogue. method estimates is the “average causal effect”
This dialogue is not achieved without gaps and – a reduction from both the individual and col-
gray areas. One example in this respect is the lective point of view. Such reductions – logical
important link between health promotion pro- transitions that are necessary and inevitable if
jects and knowledge developed through epi- the method is to be workable – construct rep-
demiological risk studies. This link occurs in resentations divorced from the complexity of
studies that articulate with other multiple ap- the processes. The problem is that transforma-
proaches (for example, studies on vulnerability tions produced through risk studies tend to be
to AIDS), which integrate the dimensions of used without considering the shifts in logical
personal behavior, social context, and organi- levels they produce. The strict limits on applying
zation of institutional programs (Mann et al., risk estimates are not properly considered, thus
1993; Ayres et al., 1997). Many projects that de- “deleting” important aspects of the respective
fine themselves as promotion also point to oc- phenomena (Czeresnia & Albuquerque, 1995).
cupational and environmental exposure as ori- This “deletion” is not value-free. On the
gins of disease. They propose encouraging such contrary, cultural meanings proliferate in it.
behavioral changes as exercise, use of seat The options involved in the process by which
belts, and stopping smoking and use of alcohol something is both revealed and concealed cor-
and other drugs. respond to interests, values, and needs. The de-

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708 CZERESNIA, D.

velopment of risk analysis was linked to a cul- of applied research, clinical experiments, and
tural process that constructed an individual- public health (Jenicek, 1997). How is a “best ev-
ist Man, faced with the need to deal with the idence” finding, formulated through clinical
disaggregating forces of nature and society epidemiological knowledge, to be related to
through a logic of order and protection and clinical experience and public health? What are
who invested little in improving relations with the mediations between operational criteria
others by strengthening his own autonomy and practical decisions? How are technical
(Czeresnia, 1997). “good recommendations” to be translated into
Considering that one of the main aspects in action ( Jenicek, 1997)? No technical protocol
the notion of health promotion is to stimulate can solve the implementation of “good prac-
autonomy, the challenge that arises involves tice”, which does not disqualify the relevancy
far-reaching transformations in how one deals of constructing protocols that optimize infor-
with such representations. There can be no mation on procedures (quite the contrary).
proposing “objective, quickly executable rec- There can be no working properly and practi-
ommendations” that will form a capacity to ap- cally on constructing the idea of health promo-
propriate information without the “risk” of val- tion without facing two fundamental, connect-
ues being incorporated uncritically. Clarity as ed issues: the need for philosophical thinking
to the values contained in the different pro- and the consequent reconfiguration of educa-
motion projects is one of the main problemat- tion (communication) in health practices.
ic points in the proposal. Any practice in health Philosophical discussion is considered
promotion presents points of view as to what crudely as “dilettante”, hovering above life and
is “good health”. The general idea of promot- the real world. However, without it there is no
ing health conceals deep-rooted theoretical way to deal with the gray areas that emerge as
and philosophical tensions (Seedhouse, 1997). we seek to dialogue and flow between the dif-
Health promotion proposals are even open to ferent dimensions in the complexity of health.
the possibility of broadening practices to in- Without reflection, there is no way to meet the
corporate alternative rationalities complemen- challenge of translating information generated
tary to the ones characteristic of traditional by the production of scientific knowledge into
public health discourse. Diversity is salutary to actions that can effectively promote social and
the extent that its theoretical foundations are environmental change, as well as changes in
made explicit. “unhealthy” behavior by subjects. The emerg-
It is with this care that one should consider ing challenges are not resolved simply by ap-
proposals such as that of evidence-based med- plying new models; the question of education
icine, which use essentially epidemiological is not solved merely with information and
criteria and methods to systematize the results technical capacity-building.

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