N39e21214286-ING-PDF.pdf
Documento PDF (282.3KB)

Exibir conteúdo Baixar

                    Review article

Possibilities and Limits of Subjectivity in the Face of
the Health-Disease Process: Canguilhem, Lukács and
the Pioneers of Collective Health
Diego De Oliveira-Souza
PhD in Social Work. Bachelor's degrees in Nursing and Sociology
Universidad Federal de Alagoas. Arapiraca, Brasil
diego.souza@arapiraca.ufal.br

Abstract
This essay aimed to analyze some aspects of subjectivity's role in normalizing health
and disease as phenomena materialized in individuals and collectivities. To do so, it
rescued the contributions of Georges Canguilhem in “The Normal and the Pathological”,
where the possibilities of the subject to normalize life in the face of a new
pathophysiological state were highlighted. Subsequently, we recovered the categories of
work, objectification, exteriorization, and alienation in Georg Lukács' “Ontology of Social
Being” to show objective limits to subjective capacity. Finally, we show how this debate
was conducted among the pioneers of Collective Health, especially under the influence
of Canguilhem. At the same time, we show that some aspects of Marxian theory on the
objectivity-subjectivity relation are present in the arguments of the authors of Collective
Health, which may bring them closer to the Lukacsian debate. Given this, we conclude
that the subject still has aspects to be deepened in Collective Health and that Lukács'
theoretical categories can contribute to mitigating excesses and filling gaps.
Keywords: Pathological; Disease; Collective Health; Canguilhem; Lukács.

Received: 06/21/2024| Evaluated: 08/21/2024 | Accepted: 09/04/2024 |Published: 04/02/2025
Esta obra está bajo una Licencia Creative Commons Atribución-NoComercial-CompartirIgual 4.0
Internacional.
Correspondence: Diego De Oliveira-Souza. Universidad Federal de Alagoas. Avenue Manoel Severino BarbosaBom Sucesso, Arapiraca, Brasil. Email: diego.souza@arapiraca.ufal.br
¿How to quote this article?
De Oliveira-Souza, D. (2025). Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process:
Canguilhem, Lukács and the Pioneers of Collective Health. Prospectiva. Revista de Trabajo Social e intervención social, (39),
e21214286. https://doi.org/10.25100/prts.v0i39.14286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286 • Universidad del Valle - Cali, Colombia

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

Posibilidades y límites de la subjetividad ante el
proceso salud-enfermedad: Canguilhem, Lukács y los
pioneros de la Salud Colectiva
Resumen

2

El objetivo de este artículo fue analizar algunos aspectos del papel de la subjetividad
en la normatización de la salud y/o la enfermedad, como fenómenos materializados en
individuos y colectividades. Para ello, rescató las contribuciones de Georges Canguilhem
en “Lo normal y lo patológico”, que destacan las posibilidades del sujeto para normatizar
la vida ante un nuevo estado fisiopatológico. Posteriormente, recuperamos las categorías
de trabajo, objetivación, exteriorización y alienación de Georg Lukács en “Para una
ontología del ser social”, con el fin de mostrar que existen límites objetivos para la
capacidad subjetiva. Por último, demostramos cómo este debate se llevó a cabo entre los
pioneros de la Salud Colectiva, especialmente bajo la influencia de Canguilhem. Al
mismo tiempo, mostramos que algunos aspectos de la teoría marxiana sobre la relación
objetividad-subjetividad están presentes en los argumentos de los autores de la Salud
Colectiva, lo que puede acercarlos al debate lukacsiano. En vista de esto, concluimos que
el tema aún tiene aspectos que deben profundizarse en la Salud Colectiva y que las
categorías teóricas de Lukács pueden contribuir para mitigar excesos y llenar lagunas.
Palabras clave: Patológico; Enfermedad; Salud Colectiva; Canguilhem; Lukács.
Summary: 1. Introduction, 2. Theoretical-conceptual reflection, 2.1 Canguilhem's
contributions to reflect on the role of subjectivity in the definition of normal, pathological,
and illness, 2.2 Objectivity-subjectivity: thinking with Lukács, 2.3 Dialoging with some
pioneering authors from Collective Health, 3. Conclusions, 4. Bibliographic references.

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

1. Introduction
This essay intends to analyze subjectivity's role in normalizing health and disease (or, more
precisely, of the health-disease process) as a concrete phenomenon materialized in individuals
and collectivities. Subjectivity is considered from a generic point of view (dimension of social
being in general) (Engels & Marx, 2007; Garcia & Moreira, 2020; Lukács, 2012), but especially from
a particular point of view when it is concretized in the experience of subjects facing a pathology
or a new state of health.
The relevance of this issue resides in the stance of the positivist-based biomedical model
that considers health (actually, disease) as an object that can only be defined by the parameters of
science or the physician (González-González, 2008). In fact, under this perspective, subjectivity
has been treated as something that should be excluded from research and intervention because it
could compromise the scientificity of the process (Díaz-Narváez, 2014).
Confronting this way of thinking, various perspectives that address the subject of
subjectivity have offered arguments to rethink its role in the definition of the health-disease
process and, consequently, of medical practice itself, of scientific health. One of the most
emblematic contributions is that of Georges Canguilhem (Czeresnia, 2010; Neves et al., 2017), a
French physician and philosopher who published his doctoral thesis defended in 1943, with later
additions under the title The Normal and the Pathological.
Canguilhem's (2009) arguments are essential to understanding how illness (and its
normalization) has a historically and socially constructed meaning and how the individual's
experience in the face of a pathological process is valuable for changes in these meanings.
Despite the importance and influence of this author's arguments, including for (Latin
American) Collective Health (De Carvalho-Mesquita Ayres, 2016), We start from the postulate
that several aspects of the relationship between objectivity-subjectivity could not be
problematized by the French author at that time, which was reproduced as gaps or excesses in
subsequent debates. We believe that some limits (but also possibilities) that exist in such a
relationship can be identified based on Marxist literature, such as the contributions of Lukács
(2018) in “For an Ontology of Social Being”, which will possibly contribute to fill the gaps or
mitigate the excesses (Castro, 2013).
Against this background, we propose a debate that crosses the arguments of Canguilhem
and Lukács to sediment them in Collective Health. To this end, we present three subsections of
reflection, first by examining subjectivity's role in Canguilhem's (2009) “the normal and the
pathological”. In the second subsection, we bring Lukacsian contributions to the objectivitysubjectivity relation. In the third subsection, we retrieve the Collective Health current, formerly
Latin American Social Medicine, to show how Canguilhem's arguments were incorporated and
Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

3

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

how a dialogue with Lukács can contribute to moving forward from Canguilhemian
reverberations.
Finally, in these introductory notes, we highlight the relevance of Collective Health for the
global debate, for its disruptive character in the face of the status quo (Pinheiro et al., 2023).
However, it has been more widespread only recently in English-speaking countries (Waitzkin et
al., 2001). In a commentary on the book “Critical Epidemiology and the People's Health” by Breilh
(2021), one of the pioneers of Collective Health, the editor of the Lancet, Richard Horton, stated:
“Breilh's manifesto is not just about advocating a new method. It is also a movement aimed at
mobilizing society: a critical science, but also a radical and emancipatory one” (Horton, 2023, p.
12).
Indeed, Collective Health shows potential for a critical debate on the role of subjectivity,
aiming for new ways of investigating and intervening in the health-disease process beyond the
instituted scientific parameters.

2. Theoretical-conceptual reflection
2.1 Canguilhem's contributions to reflect on the role of subjectivity in the
definition of normality, pathology, and disease
4

Canguilhem's (2009) conception of what constitutes the normal and the pathological
involves critically analyzing the ideas of earlier thinkers, particularly Auguste Comte, Claude
Bernard, and René Leriche. Although the conclusions of these authors are varied, their general
reflections focus mainly on quantitative aspects, establishing metrics and parameters to define
the boundary between the normal and the pathological (Mascaro, 2020).
Canguilhem (2009), however, goes beyond this approach, highlighting the importance of
the normativity of the subject within the context of the relationship between physiology and
pathology. He argues that the pathological cannot be considered a quantitative variation of the
normal but represents a qualitatively different form of the norm of life. Thus, Canguilhem (2009)
challenges the conventional view by asserting that the pathological state can be considered
normal since it reflects an intrinsic relation to the normativity of life, even if it is different from
the physiological normal.
The author emphasizes that some norms shape every condition of life, and the transition
between states involves the individual's ability to adjust to new norms. From this perspective,
health is defined as the subject's capacity to be normative, even in pathological conditions. On the
other hand, illness is not confused with pathology since it is only established when the subject
loses the normative capacity, that is, to institute new norms to continue life in the face of a new

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

state. Therefore, the disease becomes defined regarding the subject (emphasis on subjectivity)
based on its normative capacity (Canguilhem, 2009).
The analysis proposed by Canguilhem (2009) focuses on the qualitative dimension of
stabilizing life through the normative action of the subject, even in the face of a pathological
normal. He emphasizes the importance of recognizing the relativity of the process, where the
definition of illness cannot be reduced exclusively to scientific or medical parameters, but is based
on life history (the previous normal state) and on the loss of the subject's ability to adapt to new
normative circumstances (moving from the physiological normal to the pathological normal).
Of course, the normativity of the individual occurs within flexibility that becomes possible
amidst the collective (social) construction of norms, which establish physiologically possible
ways of being in a given context (Le Blanc, 1998; Safatle, 2015). Although the normal is associated
with the normativity of the individual at the center of the process, Canguilhem (2009) recognizes
the existence of norms within the genres of life (commonly called ways of living life).
In the second part of his work, Canguilhem (2009) strives to connect the vital (and thus the
norm) with the social sphere, raising this connection to a new level by considering collective
demands about the norm and vice versa. The Canguilhemian discussion is more elaborate at this
point, partly due to the twenty years of maturation that elapsed between the writing of the first
and second parts of "The Normal and the Pathological."
It is worth noting that Canguilhem (2009) draws attention to social normativity, which,
unlike natural normativity, does not inevitably produce an effect but presents itself as a
possibility. It is a “possibility of reference when it has been instituted or chosen as an expression
of a preference and as an instrument of a will to replace an unsatisfactory state of affairs with a
satisfactory state of affairs” (Canguilhem, 2009, p. 109).
While in the relationship between norm and life, Canguilhem (2009) places the horizon of
the living organism to remain stable in a new level of normality instituted by the individual in
the relationship with himself; when it comes to the social sphere, he emphasizes that norms are
correlated within a system capable of conferring a certain social unity in the acts of normalization.
Finally, in the first part of Canguilhem's work (2009), there is a perspective of relativity and
even a certain vitalism and organicism (Cairus & Gallucci, 2019; Ferreira de Almeida, 2017;
Safatle, 2011), the second part of the work extends the argumentation in the direction of the
understanding of social organization, based on the correlativity of norms. That social sphere, in
turn, imposes demands on the history of vitality (the genres of life), from which physiological
modes of being are confronted by normative individuals in the face of changes in their state.

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

5

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

With this in mind, we can affirm that Canguilhem's contributions underline the possibility
of the role of subjectivity in the definition of the normal, opposing the perspective that defined it
through a mathematical prism. Thus, Badiou (2013) considers Canguilhem part of the tradition
of contemporary French philosophy (from Jean-Paul Sartre to Gilles Deleuze), which, although
plural, has a common feature: the question of the subject. In Canguilhem, although a theory of
the subject is not made explicit, the emphasis on the role of subjectivity points to the centrality of
a subject that is not separated from its existence but is constituted through it. In a kind of
philosophy of life, the concept of normal, pathological, and illness is defined in the synthesis of
the experience of the subject inseparable from existence, in which subjectivity plays an active and
preponderant role (Badiou, 2013).

2.2 Objectivity-subjectivity: Thinking with Lukács
From what has been discussed, it is possible to recognize that there are theoretical elements
proposed by Canguilhem that contribute to thinking about health beyond illness, which, in turn,
goes beyond biologics. While Canguilhem's work reveals the rich possibilities of subjectivity, we
argue that Lukács' contributions shed light on some limits.

6

Looking under Canguilhemian lenses, the individual can institute a new set of norms to
follow in front of a pathological state with normality, albeit in a qualitatively inferior state to the
previous one. However, in that author's theory, the understanding of the role of subjectivity is
clothed with too much autonomy about the ontological priority of objectivity. This leads us to the
following questions: To what extent can the individual subjectively normalize his or her state of
health? To what extent does what is normalized by the individual or what is legitimized by the
social system of norms reflect the actual social process?
Our problematization is supported by the thoughts of Georg Lukács, for whom the
construction of subjectivity takes place in the particular moment of externalization, which in turn
is consubstantiated within the process of objectification (Brandão-Holanda, 2019; Vedda &
Infranca, 2012). Indeed, this process is essential to explain how individuals and human groups
act and think “normally” daily, in constant mutation.
Lukács (2018) posits the objectivity-subjectivity relation, taking the labor category from
Marx and capturing the processuality of social beings in their self-construction. Lukácsian
ontology emerges as one of the main works that relocate Marxism in Marx's direction,
understanding theoretical categories as determinations of reality and not only as logical-formal
constructions (Castro, 2019; Tonet, 2013).
In the Lukacsian-Marxian perspective, subjectivity and objectivity are mutually
determined, with the predominance of objective determination (Tonet, 2013). This means that
since Marx, the subject's active role (therefore, of subjectivity) is recognized but within limits set
Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

by external objectivity. This conception breaks with subjectivism but also with Marxist
perspectives that only “see” the determination of objectivity for subjectivity.
The foundation of this understanding lies in the understanding of work as original praxis,
the founding activity of social beings. According to Marx (1988), work is the activity through
which the human being, seeking to satisfy concrete needs, transforms nature into something
useful, therefore possessing use value.
It is a teleologically directed process, which exists as an ideal project (previous ideation) to
subsequently exist in objectivity (moment of objectification), although without absolute identity.
However, the previous ideation is not born spontaneously in subjectivity; it is not a mere logical
elaboration of the subject but consists of the result of the confrontation of the subject with the
objective reality, which determines its needs (Lessa, 2011). Moreover, the transformation of nature
into that which the subject needs occur within the possibilities of the causality proper to the object
under transformation (Lukács, 2018).
Work always implies a bidirectional transformation since, at the end of the process, the
human being has also been transformed, acquiring new skills, new knowledge, and, above all,
creating possibilities and needs beyond the individual sphere, as these energize social life (Lessa,
2014). For Lukács (2018), this dynamic is reproduced in any human activity, understood as praxis.
7
Objectification is not a homogeneous process, even if it is unitary. Nor is it a unidirectional
process, although its essential result is modifying objective reality. According to Lukács (2018),
objectification encompasses a particular moment of retroaction of objectivity on the subject,
essential for the constitution of individuality, a moment called exteriorization.
The moment of exteriorization marks the point at which the history of the product of labor
is separated from the history of its creator and, because of this, can recoil on the subject,
constituting its subjectivity (Alcântara, 2014). Based on this discovery, Lukács (2018) ratifies the
predominance of objectivity over subjectivity, although the latter can also provoke
transformations in objective reality. It is convenient to the caveat that it is not a matter of
anticipation but of ontological predominance in the face of a dialectical relation of coexistence.
As more objectivations and externalizations occur - in the constant relationship between
classes, groups, and individuals - the complexity and richness of social beings and the
opportunities for connection between individuals and humanity increase. Through these
moments of objectification-exteriorization, each human being tends to condense into him/herself,
a part reflecting the human genus, which contributes to historically determined self-realization
and self-knowledge (Lukács, 2018).

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

Considering this abstraction that occurs in the generic field of social being, it is also
necessary to consider how this occurs concretely in each mode of production, with its corollary
of social reproduction (Lessa, 1995). At this point, Lukács (2018) notes the relationship between
externalization and alienation of the capitalist type, with the unfoldings for subjectivity. Although
exteriorization is essentially a positive and enriching process of the subject, it can become
subordinated to alienating imperatives in the sphere of societies in which class relations
dominated by exploitation and alienation predominate. Such a condition creates obstacles to the
connections between individuals and humanity's potentialities, hindering the full development
of subjectivity and qualitatively lowering the objectivations-exteriorizations.
When it comes to capitalism, the root of this relative (never absolute) gap between the
individual and humankind lies in the fetishism of the commodity, when the products of labor
come to dominate their producers, in the process of humanization of the commodity and
reification of the human being (Marx, 1988).
In the capitalist mode of production, the transformation of nature is predominantly
oriented towards the production of value, materialized in exchange value in the market. That is
to say, an abstract form of labor, emptied of the qualities that determine the diversity of the use
values produced, dominates social relations, which come full circle to revolve around relations
between things.
8
This productivity limits individual and collective capacities for self-knowledge, selfrealization, and normalization of life in a consciously directed way, although it does not hinder
them. Alienation in capitalism, unlike externalization, is the foundation of dehumanization since
it determines an automatic and spontaneous operation of everyday relations to guarantee the
historical repositioning of capitalist relations, albeit on new forms.
These spontaneous reifications lead to conditioned reflexes of the individual, even in his
decisions and values. For Lukács (2018),
[...] the more the everyday life of human beings - still provisionally in the sense so far indicated
- creates reified forms of life and life situations, the more efficiently the human beings of
everyday life adapt spiritually [...]. They become accustomed to specific reified dependencies
and develop in themselves - again, possibly, on average, not necessarily socially - a general
adaptation to alienated dependencies. Now, it is clear that the reification, the transformation
of the reaction to everyday life purely through reflexes conditioned by the development of the
productive forces, by the socialization of the social everyday life shows increasing tendencies:
they influence, for example, the personal behavior of a coachman of earlier times much less
than that of a car driver of our days. (p. 579)

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

However, it is important to emphasize that the constant conditioning of subjects to the
reified every day is not inevitable since there is always room for resistance and transformation,
which means recognizing the active capacity of subjectivity. Subjectivity is confronted with
limitations in the bulk of everyday praxis, but collective (say, class) consciousness can play a role
in overcoming the objective bases of alienation in historical terms.
The argument presented by Lukács (2018) offers an illuminating insight into the
constitution of everyday normality. He sees it as a set of conditioned reflexes that manifest
themselves in reified forms of life and situations. In this context, humans adapt to everyday life,
moving towards a general adaptation to authentic things determined by alienation.
Thus, when we point out certain limits of Canguilhem's (2009) perspective, we need to do
so by considering two different levels of abstraction. First, we need to highlight the inherent limit
of subjectivity in praxis, for it can only (re)elaborate due to the feedback of objectification on the
subject, the moment of externalization. Already at a second level of abstraction, the limits become
even more evident, especially about the exercise of normativity of the individual or the
constitution of a system of correlated norms. Here, abstraction is brought to the concreteness of
the conditioned reflexes of the capitalist every day, revealing that the "genres of life" are, in their
essence, reified situations and forms of life.
Given this, we recognize the valuable contribution of Canguilhem (2009) in raising the role
of the subject to a new level regarding the understanding of health illness beyond the narrow
vision of positivist science. However, some gaps in this way of understanding the role of
subjectivity are consubstantiated in the absence of the discussion of objectification and
externalization, originally founded on the act of work.
Even when Canguilhem (2009), in the second part of his book, stresses that the
normalization of life takes place within a social system of related norms, he does so on the
assumption that there is too much subjective power in defining what lived phenomena are. For
an ontology of historical-dialectical materialist basis, the lived phenomena possess exteriority
about the subject and, therefore, exist objectively and independently of the subjects'
consciousness about such existence. However, those subjects in their relations produce them.
The awareness of these phenomena, as well as their transformation, is possible and
necessary. However, it occurs within an objective historical process constructed by human beings,
but not to their liking.

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

9

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

2.3 Dialoguing with some pioneering authors of Collective Health
Initially, it is necessary to clarify that Collective Health is a field that differs from Public
Health, mainly because it criticizes the positivist paradigm of the latter. It is a field developing
from Latin American Social Medicine, constituted in dialogue with the Social and Human
Sciences (especially with Marxist aspects) since the 1960s (Carmona-Moreno, 2020; DuarteNunes, 1994; Souza, 2023).
The concern of this new field, among other things, is to offer a theoretical-methodological
framework capable of explaining the social dimension of health beyond the causalisms and
dichotomies of Public Health sustained by traditional epidemiology (Breilh, 2013; Pinheiro et al.,
2023). This means also glimpsing health practices that break with the biomedical model and the
hospital-centric logic to give way to actions and services articulated collectively, from the
structuring of health systems that prioritize health promotion to the struggles for societal
transformation (Paim, 1992; Almeida-Filho, 2013).

10

In the meantime, Canguilhem's influence is perceived by some pioneering authors in this
field, especially evidenced by the incorporation of his conception of normal and pathological and
by the concept of ways of going through life (Ávila-Dantas & Almeida-Filho, 1999). This is the
case of Anamaria Testa Tambellini, in her doctoral thesis, when she analyzes traffic accidents as
social phenomena embodied in the health-disease process. On the occasion of the definition of
this process, the author incorporates the Canguilhemian thought since she considers that the
disease cannot be defined only by the physician but by the patient in his own experience. For
Tambellini-Arouca (1975):
The illness becomes that which makes him/her suffer, impairing normal life activities.
Therefore, its definition comes from the patient and not from the physician. Consequently, a
person is not ill only to others but also to her/himself. (p. 58).

In a similar direction, Sergio Arouca, in criticizing Preventive, also in his doctorate thesis,
affirms that:
Medical care is directed to human needs, considered as conditions of health and illness, which
we understand in the sense of Canguilhem (1971) as unprecedented ways of 'walking life,' in
which life, comparatively and historically, rejects the norms of illness to affirm the normativity
of health. (Arouca, 1975, p. 154)

Another pioneering doctoral thesis on the constitution of Collective Health was defended
in 1976 by Cecília Donnangelo. In it, the author brings a profound reflection on medical praxis,
reworking the object of intervention of the profession. At that time, the influence of Canguilhem
appeared since Donnangelo (1976) argues that a physiopathological dimension does not merely
Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

constitute the body on which physicians intervene but is socially determined by the experience
of normative subjects. For the author, “it is through the norms elaborated in collective life that
the body is dimensioned and acquires meaning by reference to the specificity of the social
structure” (Donnangelo, 1976, p. 25).
Asa Cristina Laurell, also in her thesis, published as a book in 1989, with the addition of a
second part co-authored with Mariano Noriega, does not make direct reference to Canguilhem
but takes the category "ways of walking life" from the text of Tambellini-Arouca (1975). We note
that Laurell and Noriega (1989) recognize this category as one of the pillars for defining the object
of medicine and other health professions, following Donnangelo's example, but they advance in
some aspects.
The advances are due to the emphasis on the social and objective character of the adaptation
processes and ways of going through life. According to Laurell and Noriega (1989), “it follows
[the social production of the environment] that 'ways of life' are characteristic of collectivities and
not of individuals” (p. 102). More than the individual's experience and relativity with
himself/herself to define the health-disease process, Laurell and Noriega (1989) consider the
social production of ways of living as the decisive dimension to set the limits within which
individuals act.
It is on this point that Marx's theory strongly influences the authors' argumentation since
they place the cornerstone of the ways of life in the work process, even before the experience of
the subjects, either with themselves or collectively. In other words, these authors “[...] place the
key to understanding the human biopsychic process in the process through which man
appropriates nature by transforming it and transforming himself, that is, in the work process”
(Laurell & Noriega, 1989 p. 103).
Therefore, thinking of the body as an object of health praxis (even if understood as
something socially determined) is insufficient. The argumentation of Laurell and Noriega (1989),
along the lines of Marx, defines this object as the human biopsychic nexus, considering it to
express how the collectivity of bodies is inserted in the spheres of production and social
reproduction.
By considering the labor process and, consequently, the capitalist production process as the
key to defining the limits within which subjects act, Laurell and Noriega reach the categories of
prior ideation (the activity oriented to an end) and alienation. Let us see in the words of the
authors themselves:
That quality of work (being an end-oriented activity) is one of the keys to understanding the
historical specificity of human psychological processes. Thus, while this quality is only a

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

11

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

potentiality until it is realized, it tends to be denied to most workers when work assumes an
exploited and alienated form. (Laurell & Noriega, 1989, p. 104)

This dimension of the health-disease process is also addressed by Breilh (1977) in his
master's thesis, but in this case, without an interlocution with the Canguilhemian categories. This
author is the precursor of social determination of health when, through historical-dialectical
materialism, he opposed the causalisms of traditional epidemiology.
To this end, Breilh (1977) situated the object of critical epidemiology in Marxian categories,
emphasizing the indispensability of the dimensions of reality (universality-particularitysingularity) to analyze health disease. Along this path, the author highlights the spheres of
production and social reproduction to capture universality, the idea of social subject (linked to
the social class category) to address the epidemiological profiles that mark the particularities, and
the insertion of individuals in social production/reproduction as expressions of the singular
dimension of reality.
It is precisely in the debate on the social subject that Breilh also approaches alienation as an
objective determination on subjects:
[...] not as a power of their own [...] but as an alien power, situated apart from them, which

12

they do not know where it comes from or where it is going and which, therefore, they can no
longer dominate [...] the social subject is lost, falls latent, begins to represent itself as something
alien. (Breilh, 1977, pp. 92-93)

In taking stock of the issues raised by some of the pioneers of Collective Health, we ratify
the important contributions of Canguilhem. However, above all, the power of Marxian-Lukacsian
thought to advance in the face of the excesses attributed to subjectivity or the gaps to be filled. It
must be recognized that the biomedical model and its variants have been busy relegating the
subjects' experience to the definition of the health disease process. It is also true that some
perspectives within Marxism did not deal appropriately with the question of subjectivity but
propagated a distortion of Marx's thought, as if it only considered, mechanically, an objective
determination of an economic nature. In the face of both problematic perspectives, reflections
such as those of Canguilhem have indisputable relevance.
Canguilhem's contributions, historically, make force against the biomedical model and,
therefore, appear in the germination of Collective Health. However, as we pointed out, the
problematization of the objective limit based on the possibilities of subjectivity to determine the
genres of life is absent, which to some extent is reproduced in Tambellini-Arouca (1975), Arouca
(1975) and Donnangelo (1976).

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

Without discarding the role of the subject's experience in the face of states of normality, it
is necessary to consider on what basis subjectivity is constituted and, therefore, the subject's
possibilities of elaboration. This challenge is shown to be susceptible to confrontation through
Marxian categories, free of any mechanism, a task for which Lukács was decisive. Approaches in
this sense are perceived in Breilh's (1977) and Laurell and Noriega's (1989) arguments, although
still without the interlocution with Lukács.
The subject is still insufficiently treated in Collective Health, especially considering its
Marxist bias, which is still stereotyped as a perspective that limits subjectivity. It is not trivial that
other theories occupied that place in the referred area, for example, the thoughts of Martin
Heidegger, Michel Foucault or psychoanalysis currents (Birman, 1991; Costa-Val et al., 2017; De
Carvalho-Mesquita Ayres, 2004), which seems to us to favor a distancing from the perspective of
reciprocal determination between objectivity and subjectivity, with priority over the latter.
Therefore, our defense is that Lukascian thought contributes to this dialogue, putting the
objectivity-subjectivity relationship in “new” terms, especially by recovering the categorical pair
externalization-alienation. From this, one can continue to recognize the importance of the
subject's experience as part of the health-disease process, in its most apparent or immediate
sphere, because it directs effective teleological acts in everyday life that produce concrete effects
on the states of health-disease, in the individual and the community. However, it must be
considered that the (normative) activity of the subject presupposes, at an ontological level, the
objective mediations that determine the correlative moments of externalization 1.
In these terms, instead of merely taking subjectivity for itself (albeit collectively, as in the
ways of walking life) as a parameter to define the health-illness process and understand how
society normalizes it, one can move towards the understanding that such a process exists in
objective reality, independently of the subject's awareness of that existence (Souza, 2019; Souza &
Mendonça, 2017). Additionally, it can never be forgotten that the production of that process is
consigned to the relationship between the subjects (especially in capitalism) (Holzkamp, 2016), in
the contradictory relationship between the development of the productive forces and the social
relations of production) Moreover, its transformation implies their conscious action, mainly
against the exploitation and alienation of labor (Tertulian, 2016).

1

Laurell y Noriega (1989) They also contribute examples to highlight the limits of subjective adaptation in the process
of normalizing a new state. For them, adaptation to stress illustrates the fact that the individual involved manages
to react in a new way to stressors, but the process itself that causes stress may remain unchanged, and thus the new
norm may be complicit in this process.

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

13

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

3. Conclusions
In this essay, we had the opportunity to analyze some aspects that refer to subjectivity in
the normalization of the health-disease process. In the Canguilhemian current, with influence on
Collective Health, subjectivity is decisive in defining illness once the latter expresses the inability
of the subject to normalize life in the face of a new pathophysiological state, that is, to go ahead
with a new normality.
We also note a direct influence of Marx's theoretical categories in Collective Health,
allowing authors such as Laurell, Noriega, and Breilh to clothe the disease process objectively.
Such objectivity has nothing to do with the positivist vision of the buoyant object; on the contrary,
it expresses the dimension of reality external to the subject but can be transformed by her/him.
These authors tangentialize categories such as teleology and alienation, which are discussed
based on labor and capitalist production processes. This presence is relevant since it converges
with the Lukascian argumentation in some aspects.

14

Lukács' Ontology has the potential to debate the role of subjectivity in the health-disease
process once it demarcates its limits in the face of objectivity, which determines it as a priority.
Lukács makes this argument without imprisoning subjectivity; on the contrary, he reveals all its
creative potential through externalization as a moment conjugated to the objectification present
in work (and, therefore, in praxis in general). This seems to be the decisive point for deciphering
how objectification is, at the same time, feedback of the products of human activity on the
subjects, (re)elaborating their subjectivity.
However, in societies based on exploitation, the process of alienation involves reified
retroactions on human subjectivity, immersed in spontaneous reflections in the everyday, as well
as in more complex (authentic) reifications that, in the end, produce the subjectivities necessary
for the reproduction of exploitation and of alienation itself. At the same time, Lukács allows
subjectivities to actively perceive the essence of these processes and, consciously and historically,
transform them.
We were not able to analyze other aspects of the role of subjectivity, then of subjects, in
socially normalizing what it means to be healthy or sick. There is a broad categorical complex in
Lukács' theory that is related to subjectivity and that, in future research, can enrich the debate.
The discussion that the Hungarian philosopher develops on consciousness, reflex, alternative,
freedom, social reproduction, and ideology seems to be the expected unfolding of this dialogue
with Lukács on subjectivity in health.

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

We hope that the brief relations that we establish and the theoretical-methodological clues
launched to the debate contribute to (re) thinking about the theories and practices that sustain
Collective Health, including making it possible to join forces in its process of international
dissemination.

Funding
The author declares not having received resources for the writing or publication of this
article.

Authors’ Contribution statement
Diego De Oliveira-Souza: conceptualization, data curation, formal analysis, resource
acquisition, research, methodology, writing (original draft), writing (draft review and
revision/editing).

Conflicts of Interest
The author declares that there is no conflict of interest in the writing or publication of this
article.

Ethical implications
The author has no ethical implications to declare in the writing and publication of this
article.

4. Bibliographic References
Alcântara, N. (2014). Lukács: ontologia e alienação. Instituto Lukács.
Almeida-Filho, N. M. (2013). Contextos, impasses e desafios na formação de trabalhadores em
Saúde Coletiva no Brasil. Ciência & Saúde Coletiva, 18(6), 1677–1682.
https://doi.org/10.1590/S1413-81232013000600019
Arouca, S. (1975). O dilema preventivista contribuição para a compreensão e crítica da medicina
preventiva [Doctoral thesis, Universidade Estadual de Campinas]. Digital file.
https://www.arca.fiocruz.br/handle/icict/37787
Ávila-Dantas, M. T., & Almeida-Filho, N. (1999). Normal-patológico, saúde-doença: revisitando
Canguilhem. Physis: Revista de Saúde Coletiva, 9(1), 13-36. https://doi.org/10.1590/S010373311999000100002
Badiou, A. (2013). La aventura de la filosofa francesa a partir de 1960. Eterna Cadencia.

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

15

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

16

Birman, J. (1991). A physis da saúde coletiva. Physis: Revista de Saúde Coletiva, 1(1), 7–11.
https://doi.org/10.1590/S0103-73311991000100001
Brandão-Holanda, M. N. A. (2019). Ideology and alienation: A necessary relationship. Revista
Katálysis, 22(2), 235–251. https://doi.org/10.1590/1982-02592019v22n2p235
Breilh, J. (1977). Crítica a la interpretación capitalista de la epidemiología. Un ensayo de desmitificación
del proceso salud-enfermedad (Unpublished Master's Thesis) Universidad Autónoma
Metropolitana.
Breilh, J. (2013). La determinación social de la salud como herramienta de transformación hacia
una nueva salud pública (salud colectiva). Revista Facultad Nacional de Salud Pública, 31(supl.
1):
13-27.
http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120386X2013000400002
Breilh, J. (2021). Critical epidemiology and the people's health. Oxford University Press.
Cairus, H. F., & Gallucci, L. (2019). O vitalismo hipocrático de Canguilhem. Physis: Revista de Saúde
Coletiva, 29(2), e290209. https://doi.org/10.1590/S0103-73312019290209
Canguilhem,
G.
(2009).
O
normal
e
o
patológico.
Forense
Universitária.
https://app.uff.br/slab/uploads/GeorgesCanguilhem-ONormaleoPatologico.pdf
Carmona-Moreno, L. D. (2020). La determinación social, una visión epistemológica para
comprender el proceso salud-enfermedad. Revista Ciencias de la Salud, 18, 1-17.
https://doi.org/10.12804/revistas.urosario.edu.co/revsalud/a.9135
Castro, R. (2013). Os 40 anos sem Lukács e o debate contemporâneo nas ciências humanas. Serviço
Social & Sociedade, (114), 207–239. https://doi.org/10.1590/S0101-66282013000200002
Castro, R. (2019). Lukács: a reviravolta dos anos 1930 e a adoção da ontologia como expressão da
filosofia de Marx. Revista Katálysis, 22(2), 330–341. https://doi.org/10.1590/198202592019v22n2p330
Costa-Val, A., Modena, C. M., Onocko-Campos, R. T., & Pegolo da Gama, C. A. P. da. (2017).
Psicanálise e Saúde Coletiva: aproximações e possibilidades de contribuições. Physis:
Revista de Saúde Coletiva, 27(4), 1287–1307. https://doi.org/10.1590/S010373312017000400022
Czeresnia, D. (2010). Canguilhem e o caráter filosófico das ciências da vida. Physis: Revista de Saúde
Coletiva, 20(3), 709–727. https://doi.org/10.1590/S0103-73312010000300002
De Carvalho-Mesquita Ayres, J. R. (2004). O cuidado, os modos de ser (do) humano e as práticas
de saúde. Saúde e Sociedade, 13(3), 16–29. https://doi.org/10.1590/S010412902004000300003
De Carvalho-Mesquita Ayres, J. R. (2016). Georges Canguilhem e a construção do campo da saúde
coletiva brasileira. Intelligere, Revista de História Intelectual, 2(1): 139-155.
https://edisciplinas.usp.br/pluginfile.php/7868888/mod_resource/content/1/Canguile
m%20Saude%20Coletiva%20Jose%20Ricardo%20Aires.pdf
Díaz-Narváez, V. P. (2014). El concepto de ciencia como sistema, el positivismo, neopositivismo
y las "investigaciones cuantitativas y cualitativas". Revista Salud Uninorte, 30(2), 227-244.
http://www.scielo.org.co/pdf/sun/v30n2/v30n2a14.pdf

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

Donnangelo, M. C. (1976). Parte I - Medicina e estrutura social. In Donnangelo, M. C., y Pereira,
L. Saúde & Sociedade (pp. 10-66). Livraria Duas Cidades.
Duarte-Nunes, E. (1994). Saúde coletiva: história de uma idéia e de um conceito. Saúde e Sociedade,
3(2), 5-21. https://doi.org/10.1590/S0104-12901994000200002
Engels,
F.,
&
Marx,
K.
(2007).
A
ideologia
alemã.
Boitempo.
https://edisciplinas.usp.br/pluginfile.php/7888155/course/section/6531689/Marx%20_
%20Engels%20-%20A%20ideologia%20alem%C3%A3%20%28Boitempo%29.pdf
Ferreira de Almeida, F. (2017). Georges Canguilhem: vitalismo e filosofia biológica. In: F. Ferreira
de Almeida, M. Salomon (Eds.), De Bergson a Rancière: pensar a filosofia francesa do século XX.
Ricochete.
Garcia, I. S., & Moreira, E. R. (2020). A Categoria Trabalho em Lukács segundo a Dialética
Marxista. Revista Direito e Práxis, 11(2), 854–879. https://doi.org/10.1590/21798966/2019/47652
González-González, N. (2008). Reforma en salud: entre el modelo biomédico y el carácter social
de la salud. Atención a pacientes diabéticos no insulino dependientes. Convergencia, 15(46),
143-168. https://www.scielo.org.mx/pdf/conver/v15n46/v15n46a7.pdf
Holzkamp, K. (2016). Ciência marxista do sujeito: uma introdução à psicologia crítica (Tomo I).
Coletivo Veredas.
Horton, R. (2023). Health’s intercultural turn. The lancet, 401(10370), 1-78.
https://doi.org/10.1016/s0140-6736(22)02594-6
Laurell, A. C., & Noriega, M. (1989). Processo de produção e saúde: trabalho e desgaste operário.
Hucitec.
Le Blanc, G. (1998). Canguilhem et les normes. PUF.
Lessa, S. (1995). Sociabilidade e Individuação. Edufal, Maceió.
Lessa, S. (2011). Trabalho e proletariado no capitalismo contemporâneo. Cortez.
Lessa, S. (2014). Mundo dos Homens – trabalho e ser social. Instituto Lukács.
Lukács, G. (2012). Para uma Ontologia do ser social I. Boitempo editorial.
Lukács, G. (2018). Para a ontologia do ser social. Coletivo Veredas.
Marx, K. (1988). O capital: crítica da economia política (Livro primeiro, Tomo I). Nova Cultural.
Mascaro, A. L. (2020). Canguilhem: saúde, doença e norma. Veritas (Porto Alegre), 65(1), e35902.
https://doi.org/10.15448/1984-6746.2020.1.35902
Neves, T. I., Porcaro, L. A., & Curvo, D. R. (2017). Saúde é colocar-se em risco: normatividade
vital
em
Georges
Canguilhem.
Saúde
e
Sociedade,
26(3),
626–637.
https://doi.org/10.1590/S0104-12902017170016
Paim, J. S. (1992). La salud colectiva y los desafíos de la práctica. In Organización Panamericana
de la Salud [OPS], La crisis de la salud pública: reflexiones para el debate (151-160). OPAS.
https://repositorio.ufba.br/handle/ri/6169
Pinheiro, T. M. M., Neto-Ribeiro, F. S., & Peixoto-Ribeiro, A. P. (2023). Epidemiologia crítica e
saúde coletiva: rupturas e reconstruções. Cadernos de Saúde Pública, 39(8): e00086223.
https://doi.org/10.1590/0102-311XPT086223

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286

17

Possibilities and Limits of Subjectivity in the Face of the Health-Disease Process: …
De Oliveira-Souza

18

Safatle, V. (2011). O que é uma normatividade vital? Saúde e doença a partir de Georges
Canguilhem.
Scientiae
Studia,
9(1):
11-27.
https://doi.org/10.1590/S167831662011000100002
Safatle, V. (2015). Uma certa latitude: Georges Canguilhem, biopolítica e vida como errância.
Scientiae Studia, 13(2), 335–367. https://doi.org/10.1590/S1678-31662015000200005
Souza, D. O. (2019). Saúde do(s) trabalhador(es): análise ontológica da “questão” e do “campo”. Edufal.
Souza, D. O. (2023). “El marxismo dará salud a los enfermos”: ideia-chave da medicina social
latino-americana. Brazilian Journal of Latin American Studies, 22(45), 155-178.
Souza, D. O., & Mendonça, H. P. F. (2017) Trabalho, ser social e cuidado em saúde: abordagem a
partir de Marx e Lukács. Interface - Comunicação, Saúde, Educação, 21(62), 543-552.
https://doi.org/10.1590/1807-57622016.0482
Tambellini-Arouca, A. (1975). Contribuição à análise epidemiológica dos acidentes de trânsito [Doctoral
thesis,
Universidade
Estadual
de
Campinas].
Digital
file.
https://repositorio.unicamp.br/acervo/detalhe/57296
Tertulian,
N.
(2016).
Ontologia
do
Sujeito.
Verinotio,
11(21),
156-185.
https://www.verinotio.org/sistema/index.php/verinotio/issue/view/19
Tonet, I. (2013). Método científico: uma abordagem ontológica. Instituto Lukács.
Vedda, M., & Infranca, A. (2012) La alienación: história y actualidad. Herramienta Ediciones.
Waitzkin, H., Iriart, C., Estrada, A., & Lamadrid, S. (2001). Social Medicine Then and Now:
Lessons From Latin America. American Journal of Public Health, 91(10), 1592-1601.
https://doi.org/10.2105/AJPH.91.10.1592

Prospectiva. Revista de Trabajo Social e intervención social • No. 39 • ene.-jun. 2025 • e21214286
e-ISSN: 2389-993X • https://doi.org/10.25100/prts.v0i39.14286