For an Anthropological Medicine
“It is first necessary to try a gradation when it comes to determining the essence of anthropological medicine. The first grade would be psychoanalysis; the second, psychosomatic medicine; and the third would be anthropological medicine.”
Viktor von Weizsacker (1886–1957)
Amid the controversy over the ideologization of therapeutic behaviors and the perplexity of public opinion with the confusion generated by contradictory guidelines presented during the pandemic, it can be said that there is, at the very least, a serious problem of communication between science and society. Is it a consequence of the difficulties that science disseminators and health authorities have had to give satisfactory answers to SarsCov2?
The temptation would be to answer yes, but it is evident that the problem is not limited to the present moment. It presents itself cyclically, showing that the complexity is broader and longer-lived. In any case, the controversy is here to stay. Words and terms such as “RT-PCR”, “herd immunity”, “IgG and IgM serological tests”, “quarantine” “lockdowns” and even “vaccine reaction” have suddenly become popular and are now debated on social media, from laboratories to cafes.
Recently, under the guise of the accusation that they are all “pseudoscientific” or “untested” practices, media organizations and people hired by them have articulated irresponsible attacks against other forms of medicine, directly harming those who are undergoing treatment.
And it is under the same guise that the attacks have also come to encompass psychotherapies, yoga, relaxation practices, meditation, hydrotherapy and a multitude of other ways of treating and caring for people. In Brazil, this recent discomfort seems to have its common origin in Brasília lobbies, deeply disturbed by the introduction of integrative medicine in the SUS, through the PNPICS (national policy of integrative and complementary practices in the Unified Health System, a supra-partisan and trans-governmental plan) . It is evident that it is necessary to discern what are the practices that have a rational support, with theoretical-practical basis and research program, distinguishing them from the others.
However, the attitude, of neo-inquisitorial inspiration, comes, ironically, from a very devout “association of professional skeptics” that now antagonize – with tactics of dubious ethics – those who believe and have experienced effectiveness in other ways of conceiving and practice the art of caring. Aggressions that include patients who have made choices in these areas.
One of the central questions of medicine has been underestimated and seems purposefully absent from most contemporary epistemological discussions. The advance of techno-science in the production of pharmaceutical ingredients, associated with the increasing – and welcome – sophistication of diagnoses, produced a harmful side effect: it displaced from medicine almost all the issues related to mental suffering and the individualization of symptoms. Having said that, we ask, how can medical practices incorporate and deal with the subjectivity of each sick person?
As a rule, the solution has been to refer these patients to the systematic use of psychiatric drugs. But the solution may not lie in training general practitioners to administer psychotropic drugs. The way forward for the euphemism called “re-humanization of medicine” may lie in giving another approach, such as rescuing an anthropological perspective for medicine.
So I ask some questions: in what way is medicine, for example, different from veterinary science? What are the distinctions in clinical research carried out in humans and animals? What are the methodological differences in the apprehension of symptoms in the two specialties? And what about therapy? How are new forms of drugs investigated? What is the scientific methodology applied to investigate the effect of medicinal substances?
An old argument is used that the difference between humans and animals lies in the irrationality of the latter, but there is an error when investigating the origin of this information. Due to a lapse in translation by copyists of the Middle Ages, the hypothesis of the philosopher Aristotle that man is a rational animal as opposed to “irrational animals” was maintained for more than two millennia. In fact, Aristotle in his Historia Animalum wrote that animals use only one other form of logic.
Another distinction can be found in one of the earliest records of civilization. In Jewish axiology the first reference to the human being in the Torah, the “Hebrew Bible”, is the Hebrew word “medaber”, which means “speaker”. It would be correct to say that what really distinguishes men and animals would be the ability to verbalize, the faculty of speech.
This peculiarity, unique in human beings, is what makes us unique beings, who manage to produce narratives. Returning to the Greek philosopher, according to him, what also differentiates us from animals beyond spoken language is the ability to spontaneously evoke memory. Thus, as beings who express themselves through speech and who manage to evoke memory according to will, we can consider ourselves subjects.
How about examining where these concepts impact medicine?
It was the founder of technical medicine, the Greek physician from the island of Cos, Hippocrates, who invented clinical history and it was doctors who followed this vitalist tradition who defended that medicine should deal with the totality of subjects, and not just be limited to address your physical ailments as they invariably come along with changes in mood and mental disposition. According to Charles Lichtenthaeler, “the history of medicine could be summarized as successive returns to Hippocrates”. This disturbing synthesis is in itself an important aphorism, which deserves reflection, especially because it has a true component.
In fact, if we think about the revaluation of empirical knowledge, the observational capacity and the systematization acquired to narrate what can be verified from the clinical evidence produced or witnessed, all this increases its consistency. The “successive return to Hippocrates” occurs not because there is a nostalgic desire to revive his works, but because he seems to summarize, remarkably, the “doing” of the medical art. As Galen stated, “I do not believe, as usual, in the testimonies of Hippocrates, I believe because I see that his demonstrations are consistent; this is my reason to praise him.”
The history of medicine also helps us to remember that doctors such as Xavier Bichat, Van Helmont, Thomas Sydenham, and the German Samuel Hahnemann (1755-1843) had already suggested a way of capturing in experimental studies the result of the action of drugs when people are exposed to them: emphasizing exactly the aspect of the narrative as one of the possible methodologies to understand the suffering and pathology of sick subjects, and, therefore, decide which were the best therapeutic alternatives.
The generous space of the anamnesis (whose etymology means “to remember again”) is still a wonderful instrument, which can bring us the symptoms (whose etymology means “something more”) that, together with the signs obtained through the physical examination and the analysis of subsidiary exams, guide the physician in what is the most important aspect to support his performance and subsequent evaluation of the results.
But what results?
Many functions, cathartic and non-cathartic, come into operation when someone arrives to report what they feel and how they suffer during a consultation. The calming or cathartic function is a speech function described by Muller-Freienfels (Entralgo, 1950). It is a type of notifying function, because in the intimacy of the one who notifies there is affective leveling and, perhaps, peace. As medical historian Pedro Lain Entralgo has pointed out, “proper elocution always has a cathartic effect, albeit in very variable amounts.”
This is such an important aspect for the relational construct between patient and doctor that Entralgo still divides catharsis ex ore (produced by active utterance) and catharsis ex auditu determined by the fact of listening properly and concludes, stating: “It is not possible to build a psychotherapeutic doctrine without discussing these two forms of verbal catharsis in depth.
This ability to extract a clinical history capturing not only all symptoms, but also extracting the biopathographic aspects requires a reformulation of education in the health sciences. And it goes against the way professionals are usually taught in most medical schools. And therefore, it must result from a permanent training. Sometimes, that’s to say, it requires an untraining.
The Spanish neurologist Ramón Sarró, in his introduction to the book on medical anthropology by Viktor von Weizsäecker, made an interesting comparison from the perspective of Anthropological Medicine: “Each case is respected in its individuality and there is always a margin of indeterminacy and even mystery. Unlike Freud, the mystery in man and the divine in man are respected, and at no time is he considered to be a fully elucidated being, not even clarified in his entirety.”*
Weizsäcker reiterates that “all the cells of the organism are capable of acquiring an expressive function”. But despite this symbolic and expressive function of symptoms being a clinical reality, according to him, we should not confuse the expressiveness of a function with its translation into semiological terms”.
“The so-called materialism cannot be overcome simply by complementing the science of the body with the study of the soul. Only by introducing the subject into the object will we take a step by which we will be able to remove the danger of mere objectivity. From this point on, medical anthropology begins. ” **
Medical schools, even the best ones, generally focus on teaching doctors in the discipline of Propaedeutics and Semiology, on how to make an anamnesis, look for objective symptoms, catalog them, everything so that one can be able to form a picture plausible diagnosis of the pathology to be treated, and establish the most appropriate and effective therapy and prognosis.
The purpose of this direction is understandable. We need to find the symptoms, identify them and fit them into increasingly complex nosological trees, and thus establish a correct name for the disease. However, establishing the nosological diagnosis and dispensing the correct drugs and conduct will be enough to determine the best therapy and referral when it comes to a medicine that is based on subjects? Charles Richet, the physician-researcher who described the phenomenon of anaphylaxis, wrote, “When we delve into the general physiology and physiology of species, we can approach the physiology of individuals, which has not yet been sketched.”
As you can see, we are not referring exclusively to the so-called integrative medicines. We are talking about lato sensu medicine. If medicine wants to recover for itself the humanist tradition that has given way to the hypertrophy of biotechnology applied to the health sciences, the rescue begins with the recovery of language and the meaning of suffering for each one. Since each person has a very particular way of getting sick and also a very particular way of being healthy.
And as the French psychoanalyst Elizabeth Roudinesco explained, whenever new diseases arise, medicine also always finds new treatments. But, at the same time, when one pathology disappears, it gives way to another “when syphilis was controlled, AIDS appeared, when psychotherapy found a way to treat hysteria, we witnessed an epidemic of depression”.
There are those who argue that a division of labor has been established between doctors and psi professionals and expertise must be respected. That is, experts must solve problems in isolation: mind and body must be, once again, didactically separate.
This also means that a physician must deal with the treatment taking into account the specificity of the clinical complaint and the diagnosed disease. Now, this observation could be a way out, if and only if there was not a crisis knocking on the door of health systems. If the WHO is correct in what the report of a meeting held in Geneva in 1988 predicted, that in our 21st century we will have a prevalence of psychic disorders. After all, we would be entering what the text called the “century of depression”.
There is, therefore, a dilemma in preventive medicine that warns, on the one hand, of the excessive cost of maintaining medical-hospital resources directed towards already established diseases, and, on the other hand, the extreme dissatisfaction (multicenter studies indicate that it is worldwide) with health services around the world. This aspect has worsened a lot during the recent pandemic due to multiple factors: social isolation, unprecedented socioeconomic crisis, increased vulnerability of so-called risk groups and the enormous pressure exerted on children and adolescents during social isolation measures, after all they were widely referred to as “the main asymptomatic carriers of the virus”.
In 2018, the then Prime Minister of the United Kingdom appointed an extra Health Minister just to study and forward actions for suicide prevention, as only in 2017 there was an alert given an epidemic of suicides where 4,500 people took their own lives. we still don’t know the extent of the psychological damage that the health policy of systematic social isolation – the induced phobia – will cause in the population, however preliminary studies already indicate that the rates of depression and mental disorders of all kinds have grown in a frightening way.
Another aspect that deserves attention is to better investigate how cures occur. Researchers have noted that most epidemiological studies are aimed at understanding how diseases arise and evolve, but those that try to understand how they are cured are much rarer.
Very recently, Israeli researchers are trying — while worldwide research for three decades is looking for an effective vaccine — to study how spontaneous cures of, for example, AIDS take place in African countries. Because they ended up discovering very peculiar aspects about the self-recycling of the immune system in face of the information received by the viral aggression.
Returning to our central theme, why then the insistence on returning to a medicine of the speaker, where technology will never be excluded, but only enters as a subsidiary and accessory that is the place to which it should always have belonged? Anachronism? Nostalgia? Refusal to accept certification granted by controlled clinical trials? How about betting that it’s because there is a demand for another kind of care and listening? What is it because society demands it? Because people need to express how they feel and it is not enough just to be a source of symptom research to formulate a diagnosis and its treatment.
Therefore, at this point we need to accept that specifically human medicine is in fact a medicine of the speaker. Of a precious space where the patient can express the modality of their complaints and sufferings, with context and individual characteristics without this being excluding the line of medicine adopted.
Anthropological medicine is therefore above the curious contemporary ideological divide between skeptics and believers, between progressives and conservatives, public and private medicine, and especially between standard and integrative medicine. Anthropological medicine is the medicine of the specifically human and follows the guideline of the recommendation contained in the aphorism of the poet Alexander Pope, “the proper study for humanity is man”.
. Charles Lichtenthaeler, La médecine hippocratique: méthode experimentale et méthode hippocratique – étude comparée préliminaire, Lausanne, Les Frères Gonin, 1948.
* See Weizsäcker, “El Hombre Sick, an Introduction to Medical Anthropology” op. cit. p. XX. ** ID ibidem, p. 183 https://brasil.estadao.com.br/blogs/conto-de-noticia/por-uma-medicina-antropologica