Socioanthropological notes on community and health

Abstracts

A noção de comunidade utilizada pelos planejadores e prestadores de assistência à saúde é duplamente enganosa. De um lado, pressupõe uma aparente igualdade e ausência de conflitos entre pessoas de um mesmo grupo populacional. De outro lado, supõe uma certa possibilidade de intervenção dos serviços sobre comportamentos considerados indesejáveis, do ponto de vista do controle de doenças ou de promoção de saúde. Utilizada deste modo, acaba encobrindo a "natureza" social da população-alvo: os pobres e os desarranjos que a condição de pobreza acarreta. Para problematizar o eufemismo implícito nesta noção de comunidade, o objetivo do presente artigo foi apresentar a abordagem radicalmente relacional de Simmel para caracterizar a subordinação destes grupos populacionais às políticas e programas de atenção à saúde. Para esta finalidade, partiu-se da apropriação da noção sociológica de comunidade pelos serviços de saúde, a partir da clássica formulação de Töennies e sua influência nos autores da Escola de Chicago.

Desenvolvimento social; Iniqüidade social; Iniqüidade na saúde; Serviços de saúde; Promoção da saúde


The notion of community utilized by planners and healthcare providers is doubly deceptive. On the one hand, it presupposes apparent equality and absence of conflicts between people in the same population group. On the other hand, it supposes a certain possibility of intervention by healthcare services in relation to behavioral patterns that are considered undesirable, from the point of view of disease control or health promotion. Used this way, this concept ends up concealing the "social nature" of the target population: poor people and the setbacks that their condition of poverty causes. To bring to light the problem of the euphemism implicit in this notion of community, the objective of the present article was to present Simmel's radically relational approach for characterizing the subordination of these population groups to healthcare policies and programs. For this purpose, the starting point was the appropriation of the sociological notion of community by the healthcare services, from Tönnies' classic formulation and its influence on the authors of the Chicago school.

Social development; Social inequity; Health inequity; Health services; Health promotion


ORIGINAL ARTICLES

Socioanthropological notes on community and health

Mara H de Andréa Gomes

Departamento de Medicina Preventiva. Escola Paulista de Medicina. Universidade Federal de São Paulo. São Paulo, SP, Brasil

Correspondence

ABSTRACT

The notion of community utilized by planners and healthcare providers is doubly deceptive. On the one hand, it presupposes apparent equality and absence of conflicts between people in the same population group. On the other hand, it supposes a certain possibility of intervention by healthcare services in relation to behavioral patterns that are considered undesirable, from the point of view of disease control or health promotion. Used this way, this concept ends up concealing the "social nature" of the target population: poor people and the setbacks that their condition of poverty causes. To bring to light the problem of the euphemism implicit in this notion of community, the objective of the present article was to present Simmel's radically relational approach for characterizing the subordination of these population groups to healthcare policies and programs. For this purpose, the starting point was the appropriation of the sociological notion of community by the healthcare services, from Tönnies' classic formulation and its influence on the authors of the Chicago school.

Keywords: Social development. Social inequity. Health inequity. Health services. Health promotion.

INTRODUCTION

Notwithstanding the efforts within the social sciences regarding the need for rigor in defining the initial concepts of this field of knowledge, Tönnies is the author usually remembered in relation to the concepts of community and society. Far from being the only author, and still less the most rigorous, his most significant contribution lies in distinguishing between two types of society: the community and the association. Subsequently, these definitions were linked by Durkheim to two corresponding types of solidarity: the mechanical and the organic. Both of these authors also showed concern about indicating the forms of development that they considered to be "social organisms", of a type for overcoming setbacks of all kinds, which Durkheim identified as "social fractures": events that could put at risk the hypothetical natural harmony of societies.

The resumption of this debate, which was so prodigally discussed within the fields of sociology and anthropology over the first four decades of last century, may assist in comprehending its present consideration within the field of health. Such reflections have been accomplished by means of the interrelations between sociology, anthropology and epidemiology, through a study on risk factors related to arterial hypertension.1 1 Prado MC de O, coordenador. Prevalência de hipertensão arterial e alguns de seus fatores de risco: inquérito domiciliar em comunidades de risco do distrito de Vila Mariana. Estudo do Depto. de Medicina Preventiva, disciplina de Epidemiologia, realizado em 2003. [relatório] The study population was called the Paula Ney Community by the basic healthcare services in the Sanitary District of Vila Mariana, in the Municipality of São Paulo. This designation presents an idealized conception that is strongly incorporated but very unreflective, for enabling interventions by the healthcare services in relation to behavioral patterns that are considered undesirable from the points of view of disease control and health promotion. It is known that concepts and definitions are available for use (and abuse), but they are not always considered. However, the epistemological benchmarks for the ontological base investigated are less available. In the way that they are incorporated by the professionals "of services", this notion of community forms part of the same benchmarks that consider many of the intervention practices that they aim to guide as "ineffective" for the desired purposes.

Castiel1 indicated the need to rethink the sense and significance of the appropriation by epidemiology of the sociological concept of community in the way that it is considered in proposals for health promotion. This is a theoretical-conceptual thread that merits continuity of reflection since, in addition to allowing this strand to be taken up again, Tönnies offers the opportunity to enter into dialogue with some classic formulations and to attempt to update them with the aid of Simmel, another author who has been the subject of little debate within the health sector.

Dialogue that is almost impossible: Tönnies and Simmel

Tönnies and Simmel, who have been mistakenly and unjustly deemed equal in the conceptions by some authors, attempted to define modern community life from some of its moral and spatial characteristics. This was even before the pragmatic-utilitarian view would yield the political and administrative fruits from the urban reforms that focused on spatial localization (by segregation) of the slums and ghettos at the end of the nineteenth century.

According to Tönnies,15 the distinction between community (associated with local community or rural life) and society (urban life) is above psychological. The former is characterized by the homogeneity of its population and by a shared system of values that provide intimacy, comprehension and cooperation between people and families. The latter is characterized by heterogeneous composition, with very strongly divided work, and bonds and links based on contracts rather than affinities of any type, with a view to obtaining personal advantages, to the detriment of group interests.

This author defined sociology as "the science of how humans live together". Such living together includes relationships of reciprocal action, for which the unit would be the group, while the individual would represent the unit of psychological factors. This polarized and clearly dichotomous view served as the basis for a diversity of studies, either following the rubric of general sociology – including physical anthropology and social psychology with regard to their sociological significance – or within special sociology (subdivided into pure, applied and empirical or sociographic sociology).

Inkeles6 was a "beneficiary" of this way of distinguishing between human groupings. He grouped the conditions under which communities exist into three elements: when a set of homes is relatively concentrated within a delimited geographical area; when the people living there present a considerable degree of integrated social interaction; and when there is a sentiment of union that is not solely based on blood ties.

On the other hand, the neighborhood is a more delimited form of grouping than the preceding ones, since in this, the inhabitants interact with relative frequency and have the same sentiment of union. But as the size of a group inhabiting a given territory increases, there is an almost inevitable reduction in the likelihood of interaction between any two individuals chosen at random. According to this author, the grouping can be spoken of as a community rather than a neighborhood when the interaction between its members reduces below a certain point, since physical proximity in itself does not constitute a community.

Authors like Inkeles see the distinction between community and neighborhood from the sense of participation rather than through physical proximity, considering that community may exist even in the absence of a common location of residence. Thus, dispersed people who "think the same way", with feelings of linkage through sharing physical or spiritual values, may be considered communities. In thinking of "effective" examples of this sense of belonging at a distance, one possibility is to consider that those people who have claimed authorship of atrocities in the name of shared political-religious values over recent years constitute "communities". In any event, classifications like this have enabled detailed descriptions of specific population groups that are distributed across urban spaces that are visibly undergoing transformation, as attested by surveys carried out in the United States at the end of the nineteenth century.

But it was Simmel13 who greatly contributed towards reflections on the distinction between community and society, precisely through considering them from a relational point of view. His objective was to identify the varied nuances of domination and subordination of each in relation to the other, and within each of them, considering that conflict is included as an ingredient in the interdependence of social actions. More than the concept of "competition" underpinning the notion of "biotic equilibrium", the concept domination-subordination occupies one of the central locations within the interpretation of reciprocal action in Simmel's thinking, which Deroche-Gurcel3 (1999) defined as "intempestive sociology".

To be constituted as a discipline, sociology should focus on the forms of reciprocal actions between individuals, given the responsibility of such forms within the particular dynamics of socialization. As a discipline of knowledge, it finds its autonomy less through the claims of a particular subject than through the abstraction accomplished: a way of seeing that isolates the subject matter of the forms of socialization implicated in reciprocal action (conflict is one component of this). One of the few points at which Simmel and Tönnies come together can be discerned in this notion of reciprocal action as the substrate for delimiting sociology as a discipline, although according to Tönnies, conflict does not institute reciprocity in social actions or in communities.

The metaphor for social fracture mentioned earlier, for which Durkheim "prescribed" simple medication (its reduction), is an image that, for Simmel, would only have cognitive power if it allowed similarities to be seen in things that were different, and if it allowed two apparently contradictory characteristics to be brought together in a subordinated manner: leveling and privilege. According to Simmel, this is the contradictory subject matter of reciprocity that forms the base on which exclusion actions, spatial segregation actions and other domination actions are continually constructed.

Simmel13 is also differentiated from other authors by considering conflict and competition as cohesion factors in groups: we have the tendency to consider peace, harmony of interests and agreement as assets that are the essence of social conservation and, on the other hand, the tendency to consider all opposition as a risk to the unit that is to be (...). However, inverse opinions seem to be better grounded: these consider that a certain rhythm between peace and conflict is the form of life that is most appropriate for conservation (...). It is a fact of the highest sociological importance, one of the rare ones that are found in almost all types of groups, that common hostility towards a third party has a much greater congregational effect than does friendship towards a third party. (...) It seems that for us, humans, whose spiritual being rests on a sense of differences, a feeling of differentiation alongside the unit is always necessary, in order to made it perceptible and effective. (...) (p. 594-8). According to Deroche-Gurcel3 (p. 12), this is the tragedy in the socialization of modernity in Simmel: the model of tension between opposites that sets up perpetual combat within one person or society.

Simmel's major theme of physical or symbolic violence may also guide the search to bring disciplines together, since it is from this that this author constructs alignments of common elements of existence found between poor people, foreigners or migrants. Hatred and racism constitute manifestations of these elements: forms of violence unleashed towards these social categories that find a strong explanation in the notion of borders: [Geographical] borders are not spatial events with sociological consequences, but are sociological events in spatial form. It is not countries and territories of all types that are mutually delimitated, but their inhabitants that undertake this reciprocal action (...) Day-to-day racism percolates little by little in all places and finds part of its vehemence [in the figure of foreigners or migrants]: hatred for other people is nourished by the halo of generosity that surrounds such people and stops them from being perceived as people 13 (p. 605-8).

Thinking of social matters in a radically relational manner leads to theoretical analysis of migrants or foreigners in a similar way to how poverty is analyzed: as sociological subjects sui generis. More particularly, within situations of poverty, it is not the interpersonal relationships that make poverty (or poor people as such) the subject of a Simmel-type study, but rather it is the relationship of assistance between such people and the society in which they live. This relationship has been taken as a working hypothesis for research carried out to seek a link between community and health.

Within any field of knowledge it is not difficult to presuppose that poverty is relative, socially constructed and socially significant, since poor people are not outside of society. Simmel, however, analytically opened up this presupposition: the singular exclusion of poor people lies within the fact that they are subjected by the community that assists them... The most terrible thing in poverty is the fact that there are human beings who, in their social position, are poor and nothing more than this... The target in assistance is exactly to mitigate certain extreme manifestations of social differentiation, so that the structure can continue to be grounded in this differentiation,13 thereby allowing society – through its different types of social assistance, including health – to ensure its self-protection and self-defense (p. 453-70)

These distinctive traits of social relationships that are typical of communities and societies are expected to be retained not only through Simmel's contribution to sociological thinking, thereby helping to constitute the modern city as the subject of this thinking, but also through their recognized influence on the studies by Park on race relations and urban phenomena. This latter author is considered to be one of the exponents of the first generation of American urban sociology, as represented by the Chicago School.2,7

The "community" of the Chicago school

The first systematic empirical studies of communities, which were carried out before the First World War, were clearly guided by interest in social reform, and found their greatest acceptance within the field of urban planning. Among these studies, the great survey of New York and its results, published between 1927 and 1931 constitutes one of the most prominent precursors of the studies made by the Chicago School. Between 1912 and 1922, several studies were conducted in rural areas, sponsored by the journal The Survey.5 In England, however, the urban area of London had already been mapped out by Mayhew & Booth,8 prior to the start of this period.

In the nineteenth century, the demographic development of the United States had made it possible to present the composition of the population graphically, by means of pyramids, while a detailed description of the use made of urban land and its forms of habitation was drawn up, and the incidence of poverty, disease and crime was recorded.

Through the circulation of researchers between countries and institutions, these studies helped to prepare the environment for the systematic formulation of investigation problems, and the improvement of research methods. The grouping of these studies around what was called "human ecology" allows the creation of the intellectual discipline recognized academically as Human Ecology (...) But it was only in 1915, when Park published his suggestive article The City: Suggestions for the investigation of Human Behavior in the Urban Environment, that ecological study of the human community became systematically recognized (...), thus leading to an accumulation of objective data and also an appreciation of the importance of comprehending the human community in its social aspects and as a spiritual state (Wirth,17 p.64-5).

According to Wirth,16 all communities can become societies insofar as human social life is distinguished from plant and animal communities, through invariably involving a certain degree of communication. This author also characterized community starting from the territorial base, in which the spatial distribution of men, institutions and activities is included. It takes into account situations of living together closely (based on kinship and organic interdependence), and aspects of life in common (based on mutual correspondence of interests). On the other hand, societies consist of voluntary and contractual relationships, in which men are less directly affected by their spatial distribution.

Of the three concepts that Wirth considered basic in sociology, the concept of the social group was, in his opinion, the most "colorless" and perhaps for this reason was more inclusive than the concepts of community and society. This is because the "social group" is a generic term: [in some cases] it is better to understand a social group as a community, and in other cases as a society, [since] these are not two different species of group life, but two aspects of all human life in groups, whose ties are irreconcilable: all social groups exist both within territorial, physical and ecological ties and within a psychological-social bond. These two represent opposite poles, and any social group will tend towards one or other of these16 (p. 112-26).

This impossibility to reconcile territorial and psychosocial ties is one of the attributes of the administrative rationality that guides the production of the authors who are recognized as belonging to the Chicago School. It can be elucidated with the following formulation: When the territorial units on which our political organization rests fail to coincide with the areas of economic and cultural organization, not only does administrative inefficiency result, but also problems of disorganization of the community may arise, such as the collapse of institutions, political corruption, physical disintegration, crime and paralysis of collection action. (...) Concrete study of communities, drawing attention to this need that is inherent to research, has indicated the way forward for reorganizing administrative areas. Some of the principal difficulties encountered by those who study the problems of communities, especially urban communities, are in some way attributable to the fact that these problems go beyond the official limits of cities and tend to assume a regional scope16 (p.112-26). The bounding of the problems identified to the limits closest to the factors that were taken to be the triggering factors was the task guided by pragmatic and instrumental rationality, and this seems to have prevailed until today.

These indications show the characteristics that allowed the notion of community to be put into operation in detail by the Chicago School. Rockefeller's contribution towards creating the school was decisive, especially with regard to the administrative staff that he helped to train. After all, these urban reformers (mostly Protestants and Baptists) had rural origins and were in a city notable as an area swept by intense modernization following its almost total devastation by a great fire. The same city in which Al Capone and Eliot Ness were the most emblematic figures of the period saw the creation of the first department of sociology and anthropology in the academic world. A significant example of this systematization is in the celebrated work in which Park11 (1925) presented the "urban community as a spatial configuration and moral order", in which an intellectual movement with inverse rotation can be identified, along Simmel's conceptual sociological lines.

Park11 imagined the social structure in terms of fixed positions, while the social changes were represented by movements that could be described and measured by means of mathematical formulae. Under conditions as interesting as these, all social phenomena can in the end by subject to measurement, and Sociology will really become what some people have tried to make of it: a branch of Statistics ... (p.127-42).

It is clear that this conception would cause some problems for sociology, but Park's ability to get round them took him closer to Durkheim than to his master, Simmel: In the case of human and social relations ... the elemental units [men and women who individually come into these different combinations] are so far from representing homogeneous units that any fundamental mathematical treatment regarding these would be impossible... The result is that the social element ceases to be the individual and becomes the attitude, i.e. individuals' tendencies towards action. It is not the individuals but the attitudes that interact to maintain social organizations and produce social changes10 (p.127-42).

"Individuals' tendencies towards action" could be the target of assistance actions, and were thus guided by the school, which would be given the task of training staff capable of "controlling" undesirable attitudes and "promoting" attitudes that favored the preservation of the order that was established. Hence, the struggle between the immigrant (Capone) and order (Ness) in the "human communities" was emblematic, and topical. This struggle is still today associated with the circuit of migration, poverty and social dislocation formulated by Park11 (p. 21-7): We know that communities start to exist, expand and flourish for some time, and then decline. This takes place both in human societies and plant communities. (...) And this is one reason for the conflicts that are apparently inevitable and perennial, between the interests of individuals and the community (...) The assimilation of people born in a given place constitutes a veritable problem... but the assimilation of adult immigrants, who are seeking their place in the communal organization, is an even more serious problem (...) insofar as [the] disorder is related, in one way or another, to population movements.

From the simplest to the most complex units, taking care not to exceed the controllable limits for living together (numerical and moral), the authors of this School also dedicated themselves to the theme of "development of communities" and their types and contingencies, in order to evaluate the weighting of the modernization of the means of transportation and lighting, among other factors. Some ideal conditions would be necessary for developing communities in metropolises: a certain quantity of natural resources, enough land to make it possible to construct roads (and the latter to furnish the conditions for transportation and communication), location close to navigable rivers and an amenable climate. For the unit to appear to have relative integration, sufficient ingredients of technological progress would also have to added. And thus, criteria were put in place – rigorously administrative in appearance, but social in their control content – to make it possible to subordinate existing or recently installed communities in relation to a central city, which would start to direct such communities by means of political-administrative measures.

In the celebrated The City, McKenzie9 places a target on human ecology, for it to become a science that is comparable, with regard to precision of observation and analysis methods, with the recent science of Plant Ecology and Animal Ecology. He constructed a classification according to the functions and objectives of intervention, introducing some variations in content without, however, altering the form of reasoning: the community of "primary services" (agriculture or fisheries; mineral or wood extraction); the community of "secondary function" (with the aim of gathering in the raw materials produced in the surrounding areas and distributing them in the region); the "industrial" city (characterized by being a manufacturing and commercial center); and the community "without a specific economic base" that, even depending on others for its economic survival, had equivalent recreational, educational and political centers.

It can be seen that, for these authors, cities are considered to be "communities" or "societies", according to the functions they perform, i.e. according to the functional objectives for the whole unit. In one or another acceptance, however, a vision that is strongly adorned both with apparent traces of a certain lyrical representation, and by less apparent administrative marks, is found: the ever-present possibility of reorganizing the disorganization inherent to modernization, by means of some type of control that reinforces the existing rules or, when necessary, that promotes reorganization by means of drawing up and imposing new rules of behavior.

With regard to this latter human attribute, it appears to be completely bereft of will and capable of almost total docile subjugation to new impositions. Precisely because of the occurrence of "mental disturbances"4 associated with the increase in "juvenile delinquency"12 in Chicago, there was stimulation towards devising techniques that would put the research accomplished into practice and, in the manner of a circuit, its results would be expected to be utilized by local administration (and many results were).

After all, this was the purpose of a good proportion of the studies: to intervene in behavioral patterns and attitudes with a view to harmonizing what Park11 called the "web of life", in order to balance the conflicts coming from what was considered to be rigidity of behavior and resistance to expected changes. In this web, competition performed the function of controlling the relationships between individuals and species within the same habitat: The conditions that affect and control the movements and numbers of the populations are more complex in human communities than among plants and animals, but they present extraordinary similarities (...) when, and insofar as the competition declines, it can be said that there is a type of order that we call "society". In one word, society is from an ecological point of view, and insofar as it is a territorial unit, precisely the area within which the biotic competition has declined and the struggle for existence has taken on more elevated and more sublime forms. (...) In this way, competition reaches a situation in which it is superceded by cooperation (p.21-7). In the same anthology cited, Park states that it is interesting to note that it was the application of a sociological principle to organic life – i.e. the principle of "competing cooperation" – which provided Darwin with his first clue for his theory of evolution, [and] thus vindicated the relevance and usefulness of a sociological idea within the biological realm.11

Notwithstanding this sociological "naturalization", areas of unforeseen and transitory population that are dirty and disorganized are described as missions of lost souls, constituting the first point of settlement for migrants/immigrants and thus forming ghettos in the so-called slums. These would be areas that were kept back for speculative purposes until the land gained higher value, and areas formed by disorderly growth of the population, in which the development of the local system for transportation linking peripheral areas with the center would more often tend to bring greater numbers of people.

If this type of formulation indicates a "problem" for administrators who only have a local view, from the point of view of speculative capital it reveals a particular strategy for expanding and giving greater value to urban land. This capital expanded precisely in tow with the migratory movements resulting from the first phases of industrialization: the same movements that have so greatly assisted in expanding urban activities, including in relation to the types of collectively consumed services provided for users (health, education, housing, transportation, energy, sanitation and communication). These are the services whose expansion has characterized – and sustained 0 the most recent process of "deindustrialization" of the city of São Paulo.

According to Singer,14 the basic presupposition in the dominant administrative vision is the absence of a necessary relationship between growth of the population and expansion of the metropolitan economy, and disregard for the essential nature of the institutional intervention within the process of capital and spatial concentration of activities. In his critical rebuttal of the anti-urban criticism formulated at the start of the 1970s, Singer stated that the problem in metropolitan areas like the Greater São Paulo region resulted from the spatial concentration of activities, and not from the population. It cannot be concluded from this, however, that the agglomeration produced by decisions taken in isolation by business leaders, based on market indicators and personal inclinations, is the best course of action. Differing therefore from the census and sample descriptions that take individuals or families as their unit, migrations are characterized as social processes for which the unit is the group. This signified, in Singer's opinion, that the place that the new migrant will occupy ... is already predetermined by his previous social relationships (p.115-44), thus configuring a process for which the most recent manifestation is in the movements demanding urban action, such as the homeless movement.

Assistance for the "lost souls"

How to include the excluded is a frequent question asked among participants in the service responsible for assistance actions aimed at the population investigated. Early diagnosis for any disease is incontestably important and is presented as a universal value. It should therefore be the subject of programmed action.

For the Sanitary District of Vila Mariana (in the city of São Paulo) to fulfill its mission to include the excluded in its actions, it was necessary to involve technicians and professionals in an active search for the populations living in shantytown areas in the region. Among these, the "Paula Ney" community was chosen for starting the survey of risk factors associated with arterial hypertension.

The target population for this type of intervention needs to appear as it really is: poor people who are unable to give proof of anything. Thus, "population", "community" or other designations are used to fulfill some mission of generosity without, however, considering this to be an institutional duty. It would be as if, by simply substituting the word in the current vocabulary, the situation characterized would disappear. In such cases, poor people come into the service – when they manage to – in the situation of people with some disease, and apparently bereft of their respective origin and social identity. This is another type of transfiguration carried out by healthcare providers, who begin a series of laborious actions that also require goodwill. This virtue, however, is not enough for immediately perceiving the overlapping cost-benefit accounting rationality in healthcare. The dilemma is therefore summarized as one of its characteristics: the population "needs" to be assisted at least to provide moral benefit for those who provide such care, even before this can be constituted as a right of those who receive it. For those who think of it in this way, there is just a short step between moral benefit and charity.

What Simmel13 said in this respect was: (...) the functioning of the institutions is always more reliable when the methodological starting point in the correlation between rights and duties is the rights, which form the vector for these functions: because man is, on average, more inclined to demand a right than to fulfill a duty. To this is added the sentiment of humanity: the idea that poor people are inwardly assisted in asking for and accepting help if this is a matter of achieving a good right. For them, charity is not embarrassing, odious or degrading, insofar as it is not offered out of pity, through a sense of duty or utility, but because they have the right to demand it. In effect, now that rights and duties appear as two faces of the absolute unity of a relationship, things taken on a new appearance, when the starting point is the duty of those who give and no longer the rights of those who receive. Taking this to an extreme, poor people disappear when they are subjects bestowed with rights and ... the reason for the donation lies solely in the significance of the gesture of giving for the donor (p.455-7). This is a situation that is always pertinent, as has been seen in the research accomplished.

On the other hand, when perceptions and spatial memories are taken into account in contraposition to the anonymous decanting that characterizes living together in urban spaces, the affective resonance that personalizes the city must be considered. This makes this space simultaneously involving (when referring to a community, at moments of meeting up in the yard or in the church) and suffocating (when referring to disputes, boundaries of places, neighborhood rows, or quarrels with "revelers").

It cannot fail to be intriguing, however, that precisely this symbolic-affective dimension is associated with the idea of community in the discourse on "health". It is as if only in this way could culture and perceptions be captured as subjects of attention (in the broadest sense of the term), in their most individualized or "unitary" dimension, i.e. exactly in those ties that are most disdained in technical-professional attendance. It is as if, in living in a society (to maintain the initial dichotomy), these instituting and singular relationships would dissolve to give room for full "de-subjectivization" of these very same ties.

The authors listed are far from representing approaches to community and society as sociological subjects. Nor have they developed perspectives that can be considered more explanatory. They have been referred to in this presentation because their analyses show core concepts and approaches in some proposals for programmed interventions aimed at "health promotion", as indicated well in the article by Castiel1 that was referred to. The absence of authors and of any vast critical national and foreign critical bibliography regarding the "ecological" approach of the Chicago School cannot fail to be a serious gap, only justifiable through the fact that dialogue between these opposite slopes is difficult and requires deeper treatment that cannot be presented along these lines. The intention was to at least partially restore the sociological concepts of community and society that prompted reflections on the construction of a pilot field of research within the frontiers of fields of knowledge.

In common, the authors cited refer to the biological base for defining the situations of humans living together in "communities" or "societies", and they indicate the vital necessities that are constitutive elements in social relationships. Among these, the health-disease process can be included. With the exception of Tönnies, competition (or tense and contradictory conflict, as in Simmel) is the element that in some way constitutes the "web of life", as a web of social relationships developed to take into account the needs for distinct "natures" (biological, social and symbolic). This was the starting point in considering the concepts that are common to the fields of knowledge involved in research, among which epidemiology has the role of frontier discipline in the intellectual neighborhood constructed. However, sharing common elements requires capturing of the conflicts constituting the actions (and reflection on this). It remains to inquire about the possibility of drawing up joint analysis that would retain differentiated content for these concepts, in a particular manner for each neighbor and in conformity with the angle of observation of the situations researched.

As well as considering that the symbolic and affective dimensions do not lead to the idealized comfort provided by community life rather than by life within society, nor do they authorize the immediate establishment of any causal relationship between a disease and a given way of life. But it is by means of such idealization that the intervention measures (including both control and promotion measures) become recommendations. Thus, what should be made communal through the idea of community becomes individualized. Perhaps for this reason, this dichotomy remains, although this does not prevent continual inter-questioning and inter-negotiation of the analytical intentions (whether interdisciplinary or not), for moving forward with certain proposals for actions for certain social groups.

REFERENCES

Recebido: 20/9/2005

Aprovado: 16/3/2006

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  • Correspondence:
    Mara H de Andréa Gomes
    Departamento de Medicina Preventiva
    EPM/Unifesp
    Rua Borges Lagoa, 1341
    04038-034 São Paulo, SP, Brasil
    E-mail:
  • 1
    Prado MC de O, coordenador. Prevalência de hipertensão arterial e alguns de seus fatores de risco: inquérito domiciliar em comunidades de risco do distrito de Vila Mariana. Estudo do Depto. de Medicina Preventiva, disciplina de Epidemiologia, realizado em 2003. [relatório]

Publication Dates

  • Publication in this collection
    16 Aug 2006
  • Date of issue
    June 2006

History

  • Accepted
    16 Mar 2006
  • Received
    20 Sept 2005
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